INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection and a complaint investigation conducted on August 28, 2023 through August 30, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Avenues Recovery Medical Center At Valley Forge 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 files, the facility failed to ensure that each counselor met the required educational qualifications for the position in three of eleven applicable records reviewed.
Employee #7 was hired as a counselor by the facility on June 27, 2023. The employee possesses a Bachelor of Arts degree from an accredited university; however, there was no documentation of what the degree's major was, so the major was not able to be verified by Department representatives.
Employee #10 was hired as a counselor by the facility on October 11, 2022. The employee possesses a Bachelor of Arts degree from an accredited university; however, there was no documentation of what the degree's major was, so the major was not able to be verified by Department representatives.
Employee #14 was hired as a counselor by the facility on June 27, 2023. The employee possesses a Bachelor of Arts degree from an accredited university; however, there was no documentation of what the degree's major was, so the major was not able to be verified by Department representatives.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
As of 10/31 all counselors will have primary source verification of education completed that includes major. Human Resources Onboarding policy was approved by committee in 8/2023 to include proof of education. The Employee Onboarding Policy will be reviewed and revised as necessary to include the language of primary source verification of degree major for counselors. The revised policy will be submitted for approval to the Staff Development Committee on 11/13/23.
The Director of Human Resources is responsible for the implementation of the credentialing and privileging processes for employee onboarding with oversite by the Staff Development Committee under the Quality Assurance and Performance Improvement (QAPI) Program. The Director of HR will submit aggregated data related to timely primary source verification metrics to the applicable oversite committee, which will be recorded in meeting minutes.
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual, the facility failed to include, within their staff development program policies and procedures, a specific policy and procedures for the program indicating who is responsible and the time frames for completion of an overall plan for addressing the training needs of all staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review of the Staff Development Policy is scheduled for 10/24/23. The policy will be reviewed and revised as appropriate, which will include the feedback and observations from DDAP staff. The hospital shall ensure that the Staff Development Policy includes specific language indicating who is responsible and the time frames for completion of the overall plan for addressing the training needs of all staff. The revised policy will be submitted for approval to the Staff Development Committee on 11/13/23.
The Director of Quality & Compliance is responsible for ensuring hospital policies, including this one, are maintained, reviewed, and approved on an ongoing basis. Such approval shall be directed to the appropriate committee for review and reapproval at a minimum of once every 2 years. The Director of Quality & Compliance is responsible for ensuring hospital policies are maintained in the established electronic source that is accessible to all employees.
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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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document annual, written individual training plans for each employee, which is to be appropriate to that employee's skill level and developed with input from both the employee and the supervisor in twenty of thirty-six employees reviewed.
Employee #6 was hired as a counselor by the facility on April 6, 2023.
Employee #8 was hired as a counselor by the facility on April 4, 2023.
Employee #11 was hired as a counselor by the facility on January 10, 2023.
Employee #12 was hired as a counselor by the facility on August 23, 2023.
Employee #13 was hired as a counselor by the facility on June 27, 2023.
Employee#16 was hired as a Patient Care Tech on May 30, 2023.
Employee#17 was hired as a Patient Care Tech on April 13, 2022.
Employee#18 was hired as a Patient Care Tech on March 7, 2023.
Employee#19 was hired as a Patient Care Tech on May 30, 2023.
Employee#20 was hired as a Patient Care Tech on May 30, 2023.
Employee#21 was hired as a Patient Care Tech on June 12, 2023.
Employee#22 was hired as a Patient Care Tech on May 30, 2023.
Employee#23 was hired as a Patient Care Tech on March 21, 2023.
Employee#24 was hired as a Peer Support on November 1, 2022.
Employee#25 was hired as a Peer Support on April 4, 2023.
Employee#26 was hired as a Peer Support on March 7, 2023.
Employee#27 was hired as a Receptionist on March 7, 2023.
Employee#28 was hired as a lead plant on June 1, 2021.
Employee#29 was hired as a EMR Administrator on July 31, 2023.
Employee#30 was hired as a Unit Coordinator on March 7, 2021.
This is a repeat citation from the February 27, 2023 through March 1, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review of the Staff Development Policy is scheduled for 10/24/23. The policy will be reviewed and revised as appropriate, which will include the feedback and observations from DDAP staff. The hospital shall ensure that the Staff Development Policy includes specific language indicating who is responsible and the time frames for completion of the overall plan for addressing the training needs of all staff, The revised policy will be submitted for approval to the Staff Development Committee on 11/13/23.
The policy will require the following items:
- Requirement to complete individual training plans during first 90 days of hire to be developed with input from employee and supervisor
- Requirement for annual individual training plans for existing employees to be completed by 1/31 of each new calendar year to be developed with input from employee and supervisor
- Requirement for staff to be compliant with DDAP training requirement timelines
- Monitoring and auditing requirements for records to ensure that all files have updated individual training plans and completed trainings within the timeframes specified
- Corrective action for failure to adhere to training plan implementation and completion of required trainings
Prior to 12/25 the following will be completed:
- Completion of new individual training plan template
- Audit of files with missing individual training plans and training requirements
- Evidence of required 2023 trainings completed to be added to employee files
- Notification to supervisors of individual training requirements for staff
- Follow up with staff and supervisors regarding non-compliance with individual training requirements
- Notification to supervisors of new individual training plan expectations
The Director of Human Resources is responsible for the implementation of the Staff Development program with oversite by the Staff Development Committee under the Quality Assurance and Performance Improvement (QAPI) Program. The Director of HR will submit aggregated data related to training metrics to the applicable oversite committee, which will be recorded in meeting minutes.
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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 the Staffing Requirement Facility Summary Report and personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health-related topics training within the regulatory timeframes for the staff person's position in six of thirty-six personnel reviewed.
Employee #31 was hired as a Patient Care Tech on June 1, 2021. The HIV/AIDS and TB/STD trainings were due no later than June 1, 2023; however, both trainings were not completed as of the date of the inspection.
Employee #32 was hired as a Patient Care Tech on June 1, 2021. The HIV/AIDS and TB/STD trainings were due no later than June 1, 2023; however, both trainings were not completed as of the date of the inspection.
Employee #33 was hired as a Peer Support on June 1, 2021. The HIV/AIDS and TB/STD trainings were due no later than June 1, 2023; however, both trainings were not completed as of the date of the inspection.
Employee #34 was hired as Campus Safety on June 1, 2021. The HIV/AIDS and TB/STD trainings were due no later than June 1, 2023; however, both trainings were not completed as of the date of the inspection.
Employee #35 was hired as Campus Safety on June 1, 2021. The HIV/AIDS and TB/STD trainings were due no later than June 1, 2023; however, both trainings were not completed as of the date of the inspection.
Employee #36 was hired as Campus Safety on June 1, 2021. The HIV/AIDS and TB/STD trainings were due no later than June 1, 2023; however, both trainings were not completed as of the date of the inspection.
This is a repeat citation from the March 9, 2022 through March 10, 2022 and the February 27 through March 1, 2023 annual licensing renewal inspections.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
A review of the Staff Development Policy is scheduled for 10/24/23. The policy will be reviewed and revised as appropriate, which will include the feedback and observations from DDAP staff. The hospital shall ensure that the Staff Development Policy includes specific language indicating who is responsible and the time frames for completion of the overall plan for addressing the training needs of all staff, The revised policy will be submitted for approval to the Staff Development Committee on 11/13/23.
The policy will require the following items:
- Requirement to complete individual training plans during first 90 days of hire to be developed with input from employee and supervisor
- Requirement for annual individual training plans for existing employees to be completed by 1/31 of each new calendar year to be developed with input from employee and supervisor
- Requirement for staff to be compliant with DDAP training requirement timelines
- Monitoring and auditing requirements for records to ensure that all files have updated individual training plans and completed trainings within the timeframes specified
- Corrective action for failure to adhere to training plan implementation and completion of required trainings
Prior to 12/25 the following will be completed:
- Completion of new individual training plan template
- Audit of files with missing individual training plans and training requirements
- Evidence of required 2023 trainings completed to be added to employee files
- Notification to supervisors of individual training requirements for staff
- Follow up with staff and supervisors regarding non-compliance with individual training requirements
- Notification to supervisors of new individual training plan expectations
The Director of Human Resources is responsible for the implementation of the Staff Development program with oversite by the Staff Development Committee under the Quality Assurance and Performance Improvement (QAPI) Program. The Director of HR will submit aggregated data related to training metrics to the applicable oversite committee, which will be recorded in meeting minutes.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on August 28, 2023, the facility failed to keep the grounds of the facility clean, safe, sanitary, and in good repair at all times for the safety and well-being of residents, employees and visitors. Additionally, the facility failed to keep the exterior of the building and the building grounds or yard free of hazards.
there was refuse placed on the hill behind the maintenance building.
Additionally, the following was observed on the first floor of the main building:
active bee's nest in the tanbark on the right side of the building.
stucco on the rear facade.
was coming off the first-floor entrance door.
bathroom near the receptionist desk had a stall door hinge was out of the wall with an exposed screw.
The following was observed on the second floor of the main building:
kitchen had cracked floor tiles, missing cove base molding, and metal trim was protruding from the wall, and cracked floor tiles.
conference room had loose/peeling wallpaper.
210 had a broken paper towel dispenser with sharp edges.
212 had a hole in the privacy curtain around the bed and peeling wallpaper.
216 had a missing front vent in the window air conditioner unit.
217 had a hole in the privacy curtain around the bed and a crack with missing plaster on the ceiling.
222 had a broken door.
hallway outside of bedroom 222 had peeling paint.
door to room 227 had a broken latch that did not allow for the door to closed properly.
207, 225, and 215 had chipped flooring and/or missing tiles, posing a tripping hazard.
hallway leading up to the second-floor residential area had exposed wiring, posing a safety hazard.
were blinds in bedroom 219 that were broken.
The following was observed at the Ranch House (male quarters):
old refrigerator was sitting on the back patio.
right side of the building had a loose soffit.
cement walkway and patio had cracked and crumbling cement which was a tripping hazard.
spouting had sharp metal edging.
tree root was protruding from the ground which was a tripping hazard.
The following was observed at the Ranch House (female quarters):
broken wooden post with sharp edges was near the back patio.
broken window screens were on the ground leaning against the house.
bathroom had a rusty vent.
This is a repeat citation from the March 1, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responses and Immediate corrective action related to deficiencies:
- Refuse on hill: This was removed during week of 9/1
- Bees nest: the exterminator was called and scheduled on date of finding to remove the nest on 8/29. The hospital has a contract with an exterminator for weekly inspection and treatment.
- Stucco on rear façade: There is no deficiency in the quality of the stucco. This section of the hospital is in good repair. This is a different color and can be repainted, but does not result in any risk to safety or well-being
- Bathroom near the receptionist desk: repaired week of 10/9
- Kitchen: repairs were completed week of 9/1
- 207: chipped floor repaired as of 10/12
- 210: repairs completed same day as finding
- 212: curtain has been replaced as of 10/12
- 216: new unit ordered and received week of 10/13. Will be replaced week of 10/16
- 217: curtain has been replaced as of 10/12. Deficiencies repaired as of 10/12
- 222: new door ordered week of 10/12. Will be installed upon arrival of materials.
- Hallway outside 222: Parts ordered and received as of 10/12. Will be replaced week of 10/16
- 227: Parts ordered and received as of 10/12. Will be replaced week of 10/16
- 207, 225, and 215: chipped floor tiles repaired as of 10/12
- Hallway wiring: Parts ordered as of 10/12
- 219: Parts ordered as of 10/12
- Men's Ranch House: Refrigerator removed as 10/12, soffit repaired week of 10/9, spouting removed, tree root will be removed week of 10/16.
- Cement Walkways: actively repairing during time when weather conditions are favorable for repairs (no outside temperature below 40F or rain); Prioritizing larger cracks first ? any deemed to be a tripping hazard by the Director of Facilities - and will continue ongoing repairs for smaller cracks until the 2024 when weather conditions allow complete repairs to be addressed
- Women's ranch house: post will be removed week of 10/16; window screens removed; vent repaired.
The hospital has identified the following tentative timeline for renovation start dates for second floor bedrooms and bathrooms. The tentative timeline is subject to change for a number of reasons including: (1) reprioritization of specific rooms (2) patient needs (3) changes in material availability (4) unforeseen circumstances:
Although the deficiencies identified by DDAP during the inspections have been corrected as indicated above, the hospital is planning additional renovations for continued improvement.
The only findings from this that are repeat findings are:
- 207 and 225 chipped tiles: these have been repaired and new cracked tiles have been identified in this survey. All bedrooms and bathrooms will have new flooring installed during renovations.
Room Numbers Tentative Renovation Timeline (Please note: updated timeline since last POC submission):
201 12/1/2023
202 12/1/2023
203 12/22/2023
204 12/22/2023
205 1/12/2024
206 1/12/2024
207 2/2/2024
208 2/2/2024
209 2/23/2024
210 2/23/2024
211 3/15/2024
212 3/15/2024
213 4/5/2024
214 4/5/2024
215 4/26/2024
216 4/26/2024
217 5/17/2024
218 5/17/2024
219 6/7/2024
220 6/7/2024
221 6/28/2024
222 6/28/2024
223 7/19/2024
224 7/19/2024
225 8/9/2024
226 8/9/2024
227 8/9/2024
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program.
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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 a physical plant inspection conducted on August 28, 2023, the facility failed to store all trash, garbage, and rubbish in a noncombustible, covered container.
Both outside dumpsters were observed to be open. Two broken toilets were sitting on the ground beside one of the dumpsters.
This is a repeat citation from the March 1, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The hospital identified that the dumpsters in use should be replaced with front-loading dumpsters to eliminate staff need to open the top of dumpsters.
Facilities staff has been trained on the proper cleaning and maintenance of the area with initial training on 08/30/23. The Director of Facilities completes a visual inspection of the area at a minimum of weekly. If trash is found to be outside the approved disposal containers, the Director of Facilities addresses immediately with staff and corrects on the spot. The hospital is committed to ensuring that this standard is met ongoingly.
The hospital has plans to create an enclosed garage collection area within the next year, when renovations have been completed and temporary storage pods are no longer needed to be housed in the vicinity.
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program.
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705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection conducted on August 28, 2023, the facility failed to maintain counseling areas with furnishings which are in good repair.
The large group room on the first floor had multiple chairs that were ripped/torn and had graffiti on the backs and seats.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All chairs not in good repair were removed from the group room by 10/11/23 by the Director of Facilities and replaced with chairs in good repair.
The Director of Facilities has the responsibility for ensuring that the hospital furnishings are maintained in good repair.
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program. |
705.5 (a) (2) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(2) A pillow and bedding appropriate for the temperature in the facility.
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Observations
Based on a physical plant inspection conducted on August 28, 2023, the facility failed to provide a pillow and bedding, appropriate for the temperature in the facility, for each resident.
There were pillows missing from beds in bedrooms 218, 225, 226 and 227. Additionally, there were pillows missing from beds in bedrooms 209, 223, 224, 322 and 327.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following immediate corrective action was put in place:
- Sufficient numbers of pillows were located on the date of the survey and provided to all patients.
- Additional pillows were ordered by the hospital to increase the number of pillows in hospital supply the same week of the survey
- On 9/18/2023 hospital leadership met with the leadership of the housekeeping vendor to redefine the scope of services in the contract ensure understanding of responsibilities in the ordering and replacement of linens
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program
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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 a physical plant inspection conducted on August 28, 2023, the facility failed to ensure that all bathrooms had proper ventilation by either an exhaust fan or a window.
The bathroom in bedroom 203 did not have an operable fan nor a window for proper ventilation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This bathroom is scheduled to be closed for renovation during the correction window.
The hospital has identified the following tentative timeline for renovation start dates for second floor bedrooms and bathrooms. The tentative timeline is subject to change for a number of reasons including: (1) reprioritization of specific rooms (2) patient needs (3) changes in material availability (4) unforeseen circumstances:
Room Numbers Tentative Timeline (Please note: updated timeline since last POC submission):
201 12/1/2023
202 12/1/2023
203 12/22/2023
204 12/22/2023
205 1/12/2024
206 1/12/2024
207 2/2/2024
208 2/2/2024
209 2/23/2024
210 2/23/2024
211 3/15/2024
212 3/15/2024
213 4/5/2024
214 4/5/2024
215 4/26/2024
216 4/26/2024
217 5/17/2024
218 5/17/2024
219 6/7/2024
220 6/7/2024
221 6/28/2024
222 6/28/2024
223 7/19/2024
224 7/19/2024
225 8/9/2024
226 8/9/2024
227 8/9/2024
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on August 28, 2023, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
- The bathrooms in client bedrooms 202, 203, 207, 214, 216, 217, 218, 219, 220, 223 had rust on pipes, shower rods, and heating covers. Additionally, there was what appeared to be mold or mildew located in the showers and/or bathtubs.
- The bathroom in client bedroom 216 had damaged tiles in the shower, a toilet that was propped up with tiles and drywall pulling away from the wall behind the shower.
- The bathroom in client bedroom 217 had a shower flange that was not attached to the wall and drywall pulling away from the wall behind the shower.
- The bathroom in client bedroom 223 had ceiling tiles that were dislodged.
- The bathroom in client bedroom 227 had a broken fan cover.
This is a repeat citation from the March 9, 2022 through March 10, 2022 and February 27 through March 1, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responses and Immediate corrective action related to deficiencies:
- 202, 203, 207, 214, 216, 217, 218, 219, 220, 223: Shower rods and curtains were replaced, showers were cleaned, rust on heating covers was cleaned, rust on pipes cleaned as of 10/12/23
- 216: toilet setting repaired as of 10/12/23
- 217: deficiencies repaired as of 10/12/23
- 223: fixed as of 10/12/23
- 227: repaired on date of survey
On 9/18/2023 hospital leadership met with the leadership of the housekeeping vendor to redefine the scope of services in the contract ensure understanding of responsibilities for removing mold or mildew from showers and/or bathtubs and notifying hospital leadership of facility deficiencies. Such deficiencies were noted in contractor evaluation.
The hospital has identified the following tentative timeline for renovation start dates for second floor bedrooms and bathrooms. The tentative timeline is subject to change for a number of reasons including: (1) reprioritization of specific rooms (2) patient needs (3) changes in material availability (4) unforeseen circumstances:
Room Numbers Tentative Timeline (Please note: updated timeline since last POC submission):
201 12/1/2023
202 12/1/2023
203 12/22/2023
204 12/22/2023
205 1/12/2024
206 1/12/2024
207 2/2/2024
208 2/2/2024
209 2/23/2024
210 2/23/2024
211 3/15/2024
212 3/15/2024
213 4/5/2024
214 4/5/2024
215 4/26/2024
216 4/26/2024
217 5/17/2024
218 5/17/2024
219 6/7/2024
220 6/7/2024
221 6/28/2024
222 6/28/2024
223 7/19/2024
224 7/19/2024
225 8/9/2024
226 8/9/2024
227 8/9/2024
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document that all staff were instructed in the use of the fire extinguisher upon employment in six of fifteen applicable personnel record reviewed.
Employee #1 was hired as the project/facility director on May 15, 2023
Employee #2 was hired as a clinical supervisor on September 22, 2022.
Employee #7 was hired as a counselor on June 27, 2023.
Employee #8 was hired as a counselor on April 4, 2023.
Employee #9 was hired as a counselor on September 6, 2022.
Employee #10 was hired as a counselor on October 11, 2022.
This is a repeat citation from the February 27 through March 1, 2023 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
New hire fire safety trainings were implemented as of 3/8/23 and any records for employees hired since that date will be corrected to accurately reflect the completion of such training by 12/25/23.
Fire safety training will be loaded to the LMS and the requirement to be completed will be assigned to all staff identified as not having current fire safety trainings in their staff files by 12/25/23.
A review of the Staff Development Policy iIs scheduled for 10/24/23. The policy will be reviewed and revised as appropriate, which will include the feedback and observations from DDAP staff. The hospital shall ensure that the Staff Development Policy includes specific language indicating who is responsible and the time frames for completion of the overall plan for addressing the training needs of all staff, The revised policy will be submitted for approval to the Staff Development Committee on 11/13/23.
The policy will require the following items:
- Requirement to complete individual training plans during first 90 days of hire to be developed with input from employee and supervisor
- Requirement for annual individual training plans for existing employees to be completed by 1/31/23 of each new calendar year to be developed with input from employee and supervisor
- Requirement for staff to be compliant with DDAP training requirement timelines
- Monitoring and auditing requirements for records to ensure that all files have updated individual training plans and completed trainings within the timeframes specified
- Corrective action for failure to adhere to training plan implementation and completion of required trainings
Prior to 12/25/23 the following will be completed:
- Fire Safety trainings will be uploaded to the LMS to be completed by all existing staff
- Completion of new individual training plan template
- Audit of files with missing individual training plans and training requirements
- Evidence of required 2023 trainings completed to be added to employee files
- Notification to supervisors of individual training requirements for staff
- Follow up with staff and supervisors regarding non-compliance with individual training requirements
- Notification to supervisors of new individual training plan expectations
The Director of Human Resources is responsible for the implementation of the Staff Development program with oversite by the Staff Development Committee under the Quality Assurance and Performance Improvement (QAPI) Program. The Director of HR will submit aggregated data related to training metrics to the applicable oversite committee, which will be recorded in meeting minutes.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in six of fifteen applicable personnel record reviewed.
Employee #1 was hired as the project/facility director on May 15, 2023
Employee #2 was hired as a clinical supervisor on September 22, 2022.
Employee #7 was hired as a counselor on June 27, 2023.
Employee #8 was hired as a counselor on April 4, 2023.
Employee #9 was hired as a counselor on September 6, 2022.
Employee #10 was hired as a counselor on October 11, 2022.
This is a repeat citation from February 27 through March 1, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New hire fire safety trainings were implemented as of 3/8/23 and any records for employees hired since that date will be corrected to accurately reflect the completion of such training by 12/25/23.
Fire safety training will be loaded to the LMS and the requirement to be completed will be assigned to all staff identified as not having current fire safety trainings in their staff files by 12/25/23.
A review of the Staff Development Policy is scheduled for 10/24/23. The policy will be reviewed and revised as appropriate, which will include the feedback and observations from DDAP staff. The hospital shall ensure that the Staff Development Policy includes specific language indicating who is responsible and the time frames for completion of the overall plan for addressing the training needs of all staff, The revised policy will be submitted for approval to the Staff Development Committee on 11/13/23.
The policy will require the following items:
- Requirement to complete individual training plans during first 90 days of hire to be developed with input from employee and supervisor
- Requirement for annual individual training plans for existing employees to be completed by 1/31/23 of each new calendar year to be developed with input from employee and supervisor
- Requirement for staff to be compliant with DDAP training requirement timelines
- Monitoring and auditing requirements for records to ensure that all files have updated individual training plans and completed trainings within the timeframes specified
- Corrective action for failure to adhere to training plan implementation and completion of required trainings
Prior to 12/25/23 the following will be completed:
- Fire Safety trainings will be uploaded to the LMS to be completed by all existing staff
- Completion of new individual training plan template
- Audit of files with missing individual training plans and training requirements
- Evidence of required 2023 trainings completed to be added to employee files
- Notification to supervisors of individual training requirements for staff
- Follow up with staff and supervisors regarding non-compliance with individual training requirements
- Notification to supervisors of new individual training plan expectations
The Director of Human Resources is responsible for the implementation of the Staff Development program with oversite by the Staff Development Committee under the Quality Assurance and Performance Improvement (QAPI) Program. The Director of HR will submit aggregated data related to training metrics to the applicable oversite committee, which will be recorded in meeting minutes.
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711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for not documenting an informed patient consent prior to administration of an agent were submitted and approved by the Department for the March 9, 2022 through March 10, 2022 and February 27, 2023 through March 1, 2023 annual licensing inspections. Not documenting an informed patient consent prior to the administration of an agent was again found to be a deficiency in the August 28, 2023 to August 30, 2023 licensing inspection.
Plans of correction for not maintaining each bathroom in a functional, clean, and sanitary manner at all times were submitted and approved by the Department for the March 9, 2022 through March 10, 2022 and February 27, 2023 through March 1, 2023 annual licensing inspections. Not maintaining each bathroom in a functional, clean, and sanitary manner at all times was again found to be a deficiency in the August 28, 2023 to August 30, 2023 licensing inspection.
Plans of correction for ensuring all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health-related topics training within the regulatory timeframes were submitted and approved by the Department for the March 9, 2022 through March 10, 2022 and February 27, 2023 through March 1, 2023 annual licensing inspections. Not ensuring all staff persons received both of the communicable disease trainings was again found to be a deficiency in the August 28, 2023 to August 30, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The hospital has submitted updated corrective action plans.
Updated informed consent and maintenance of bathrooms corrective action plans were approved by DDAP on 10/2/23 and 9/18/23, respectively and have been reiterated in this current submission of POCs. Training requirement POC has been submitted in this current submission of POCs.
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the narcotic treatment program failed to maintain the confidentiality of all patient records, in accordance with Federal and State laws and regulations, by not documenting a client-signed consent to release information form prior to the disclosure of information in patient records in three of seventeen applicable patient records reviewed.
Patient #2 was admitted into the hospital detox activity on June 19, 2023 and was discharged on June 26, 2023. There was documentation of billing to the funding source during the patient's treatment episode; however, there was no consent to release information form on file prior to the disclosures of information.
Patient #4 was admitted into the hospital detox activity on June 18, 2023 and was discharged on June 20, 2023. There was documentation of billing to the funding source during the patient's treatment episode; however, there was no consent to release information form on file prior to the disclosures of information.
Patient #18 was admitted into the non-hospital residential activity on June 20, 2023 and was discharged on August 10, 2023. There was documentation of billing to the funding source during the patient's treatment episode; however, there was no consent to release information form on file prior to the disclosures of information.
This is a repeat citation from the February 27, 2023 through March 1, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The hospital has identified that the current process to capture signatures on this form may have resulted in signatures not being saved in the forms. The EMR Administrator has investigated these potential form deficiencies, and identified the workflow required to ensure that signature capturing is working properly. The hospital has identified the need to train staff on the steps required to capture signature of patients on the consent to release information pcp and billing source forms. Training will be completed on or before 11/15/23. Workflow requirements have been communicated to the hospital leadership from the EMR Administrator as of 10/12/23. During the week of 10/16/23,Prior to 11/15/23 a job aid will be provided to staff completing intake paperwork with patients to ensure that they are aware of the steps necessary to capture signature.
Starting in August, the hospital has been completing monthly admissions paperwork audits to identify deficiencies in admissions paperwork, including the capture of signatures on this form. Results of audits are provided to the departmental directors to ensure that deficiencies are corrected and training needs are addressed.
Audits have occurred on the following days:
- July: 7/10/23
- August: 8/24/23
- September: 10/10/23
Audits will be completed on or before and presented to the Patient Safety Committee on the following dates (subject for rescheduling due to unforeseen circumstances):
- October: 11/22/23
- November: 12/27/23
- December: 1/24/23 |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in four of seventeen applicable patient records reviewed.
Patient #6 was admitted into the hospital detox level of care on August 26, 2023 and was active at the time of inspection. The patient received their first medication dose on August 26, 2023; however, there was no signed consent to treat form documented in the record at the time of inspection.
Patient #14 was admitted into the hospital residential activity on June 29, 2023 and was active at the time of inspection. The patient received their first medication dose on June 30, 2023; however, the patient consent to treat form was signed by the patient on July 10, 2023.
Patient #15 was admitted into the non-hospital residential activity on May 15, 2023 and was discharged on June 13, 2023. The patient received their first medication dose on May 16, 2023; however, the patient consent to treat form was signed by the patient on May 17, 2023.
Patient #18 was admitted into the non-hospital residential level of care on June 20, 2023 and was discharged on August 10, 2023. The patient received their first medication dose on June 20, 2023; however, there was no signed consent to treat form documented in the record at the time of inspection.
This is a repeat citation from the March 9, 2022 through March 10, 2022 and February 27, 2023 through March 1, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The hospital's Quality Assurance & Performance Improvement Program approved the implementation of a Performance Improvement Project on 6/30/23 for the purpose of ensuring that narcotic treatment consents are completed prior to the administration of the first dose of a narcotic agent.
Training for staff related to the requirement to obtain written informed consent and verify that consent was obtained prior to first dose of a narcotic agent was developed and implemented as of 6/22/23.
Hospital Policy "Informed Consent for Narcotic Drug Administration" was most recently approved on 7/26/2023, which includes the following:
- Before the administration of narcotic drugs, specifically methadone and buprenorphine, a signed patient Consent for Treatment with an Approved Narcotic Drug must be obtained.
Hospital Policy "Medication Administration" was most recently approved 8/9/2023, which includes the following:
- obtain a signed patient Consent for Treatment with an Approved Narcotic Drug from each patient prior to the administration of methadone.
- obtain a signed patient Consent for Treatment with an Approved Narcotic Drug from each patient prior to the administration of buprenorphine.
Since July 2023, the hospital has implemented focused monitoring of this process to ensure that hospital policy and standards regarding obtaining informed consent for narcotic treatment administration is completed timely. The hospital uses the results of this monitoring for the purposes of oversight and improvement efforts around this Performance Improvement Project. The results of the monitoring were most recently presented to the hospital's Patient Safety Committee on 8/24/2023.
Most recent audit was completed on 10/10/23
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to complete and document follow-up information regarding the patient in eight of eleven applicable patient records reviewed.
Patient #4 was admitted into the hospital detox activity on June 18, 2023 and was discharged on June 20, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Patient #9 was admitted into the hospital residential activity on June 13, 2023 and was discharged on June 16, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Patient #10 was admitted into the hospital residential activity on June 5, 2023 and was discharged on June 9, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Patient #11 was admitted into the hospital residential activity on May 30, 2023 and was discharged on June 5, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Patient #12 was admitted into the hospital residential activity on May 16, 2023 and was discharged on June 16, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Patient #16 was admitted into the non-hospital residential activity on May 10, 2023 and was discharged on August 2, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Patient #17 was admitted into the non-hospital residential activity on June 19, 2023 and was discharged on July 10, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Patient #18 was admitted into the non-hospital residential activity on June 20, 2023 and was discharged on August 10, 2023. There was no follow-up information documented in the record as of the date of the inspection.
This is a repeat citation from the February 27, 2023 through March 1, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/13/2023 the hospital approved the new "Discharge Planning and Aftercare Coordination: Policy which states the following:
"The Director of Peer Support shall be responsible for ensuring that [...] post-discharge follow-up contacts are being completed within the designated timeframe(s) and that such assessments are being documented in compliance with this policy and departmental procedures."
AND
"Following treatment discharge, Peer Support shall contact the patient to determine compliance with attending follow-up appointment(s). The following shall be documented:
a. Outcome of contact attempt
b. Compliance with attending follow-up appointment. If not attended, the barrier(s) the patient identified.
c. If the patient is still in recovery. If not, if the patient is open to receiving resources."
On 7/20/2023 the hospital's Quality Assurance and Performance Improvement (QAPI) Committee implemented a Performance Improvement Project (PIP) for "Post-Discharge Follow-Up" focused on ensuring documentation of post-discharge follow-up phone calls and patient compliance with aftercare appointments.
Starting the week of 7/14/2023, the Director of Peer Support has weekly reported (1) compliance with post-discharge follow-up phone calls and (2) patient compliance with aftercare appointments. Since 7/14/2023, the Director of Peer Support has reported 100% compliance with post-discharge follow-up.
Regarding the two patients who were cited as not having post-discharge follow-up since the implementation of the 7/13/23 policy and 7/20/23 PIP:
Patient #16 ? post discharge initial follow up was completed on 8/3/2023.
Patient #18 ? was on hospital leave on for 10/10/23 discharge and returned to VFMC on 8/16/2023. No discharge follow-up was required because patient was being monitored for return to VFMC.
VFMC leadership continues to complete weekly monitoring of these measures to ensure ongoing compliance.
Limitations of the DDAP POC module do not allow any date prior to 8/30/2023 to be entered as Corrective Action Date. Therefore all corrective actions taken prior to 8/30/2023 will be inputted with a Corrective Action date on 8/30/23
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711.53(c)(2)(iv) LICENSURE Dated Signature of Client/guardian
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:
(iv) The dated signature of client or guardian.
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Observations
Based on a review of client records, the facility failed to document a dated signature of the client on release of information forms in two of seven applicable records.
Client #17 was admitted into the non-hospital residential activity on June 19, 2023 and was discharged on July 10, 2023. There were release of information forms to a primary care physician and funding source signed by the witness on June 19, 2023; however, the forms were not signed by the client.
Client #21 was admitted into the non-hospital residential activity on August 10, 2023 and was active at the time of inspection. There was a release of information form to a primary care physician signed by the witness on August 10, 2023; however, the form was not signed by the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The hospital has identified that the current process to capture signatures on this form may have resulted in signatures not being saved in the forms. The EMR Administrator has investigated these potential form deficiencies, and identified the workflow required to ensure that signature capturing is working properly. The hospital has identified the need to train staff on the steps required to capture signature of patients on the consent to release information pcp and billing source forms. Training will be completed on or before 11/15/23 Workflow requirements have been communicated to the hospital leadership from the EMR Administrator as of 10/12/23. By 11/15/2023, a job aid will be provided to staff completing intake paperwork with patients to ensure that they are aware of the steps necessary to capture signature.
Starting in August, the hospital has been completing monthly admissions paperwork audits to identify deficiencies in admissions paperwork, including the capture of signatures on this form. Results of audits are provided to the departmental directors to ensure that deficiencies are corrected and training needs are addressed.
Audits have occurred on the following days:
- August: 8/24/23
- September: 10/10/23
Audits will be completed on or before and presented to the Patient Safety Committee on the following dates (subject for rescheduling due to unforeseen circumstances):
- October: 11/22/23
- November: 12/27/23
- December: 1/24/23 |
711.54(a)(6) LICENSURE Special Dietary Needs
711.54. Project management services.
(a) When food is prepared at the project site and preparation is not directly supervised by the parent health care facility, then the drug and alcohol project shall have written policies and procedures for its dietetic services which includes, but is not limited to:
(6) Special dietary needs.
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Observations
Based on client interviews, a review of client grievances, a review of the weekly meal menus, and the facility's Diet and Nutrition Care Manual, the facility failed to ensure the special dietary needs of clients were met.
There was documentation which showed diabetic-friendly food options were not available. It was reported that the provided food was high in carbohydrates and sugar.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The hospital is currently engaged in close monitoring of the dietary/dietician services related to special dietary needs. The dietary provider has submitted updated special diet menus to hospital leadership as of 10/12/23 which have been reviewed by the dietician and found to meet special dietary needs. Special Diet Menus were approved for patients with special diet orders that includes Regular Diet, 2g Sodium, Carb Control and Cardiac Diet.
Special diet order education was provided to dietary staff on 10/13/23. Dietary staff will begin review of diet restrictions for each patient prior to handing out patients starting on 10/16/23. Dietary staff were also retrained to follow strict diet orders on 10/13/2023..
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711.55(b) LICENSURE Data Collection & Record Keeping
711.55. Uniform Data Collection System.
(b) A drug and alcohol data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
Based on a review of patient charts, the facility's data collection and recordkeeping system did not allow for the efficient retrieval of data.
The facility was transitioning from one electronic patient record system to an another system and the Department representatives had difficulty in obtaining the needed patient information from both electronic systems.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The hospital transitioned to a new EMR in June 2023 from a legacy EMR system. A full time EMR Administrator was hired in July 2023. The hospital continues to make ongoing improvements to the new EMR, including improvements based on feedback from DDAP. The EMR Administrator is responsible for ensuring the implementation of identified improvement opportunities, at the direction of the Executive Director.
The EMR Administrator works directly with hospital leadership to ensure ongoing efforts to support sustainable efficiency and quality of patient records. Since the date of the survey, several process improvements have been implemented and continue to be implemented in the EMR, including improvements to forms, orders, and modules. Staff knowledge, streamlined processes, and efficiency of use of the new EMR have significantly increased since the survey.
The hospital continues to monitor feedback from staff, DDAP, and others to identify opportunities to improve the new EMR and streamline efficiency in retrieval of data. The Regional Director is responsible for overseeing the aggregation of system improvement opportunities and delegating the completion of necessary tasks to enhance efficiency. |