INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Luke's Hospital - Sacred Heart Campus 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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704.11(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 develop an individual training plan that is based upon an employee's previous education, experience, current job functions, and job performance in nine of nine personnel records reviewed.
Every individual staff training plan reviewed and completed for the January 2024 through December 2024 training year were not individualized and not based on the employee's previous education, experience, current job functions, and job performance. Each individual training plan only listed the Department of Drug and Alcohol Program's required trainings.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will update the training plans for the case management staff to include additional goals and training specific to the case manager based on their previous education, experience, current job functions and job performance, including feedback from each case manager regarding their training plan.
This will be completed by Jan 31, 2025, facility director will maintain training plans moving forward, ensuring case managers are making progress towards completing required training, and keeping in mind individualized training goals.
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710.22(c) LICENSURE Patient Management Services
§ 710.22. Patient management services.
(c) The service staff shall develop a written patient follow-up policy.
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Observations
Based on a review of patient records, the facility failed to follow their written patient follow-up policy in one of two applicable patient records reviewed.
The facility's policy and procedure manual stated the patient's emergency contact will be notified within 12 hours after the patient is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Patient #4 was admitted on April 22, 2024 and was discharged against medical advice on April 25, 2024. There was no documentation, in the patient record, indicating the emergency contact was notified of the patient's discharge against medical advice at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
2) During first shift, case managers will be responsible for notification of AMA discharge. Unit nurses will be responsible for AMA discharge notifications during second and third shift. This policy was reviewed with case managers during group supervision on Monday 12/16/24. CM will review policy with staff quarterly moving forward. Patient care manager will meet with nurses in upcoming nursing meeting on 1/22/2025 and review the notification of emergency contact for AMA discharges from the detox unit. After the meeting patient care manager will add the nursing meeting minutes to the meeting binder on the detox unit for future reference and review. |
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 ensure the patient's medical record contained follow-up information in three of four applicable patient records reviewed.
Patient #4 was admitted on April 22, 2024 and was discharged on April 25, 2024. There was no follow-up information documented in the record at the time of the inspection.
Patient #5 was admitted on June 17, 2024 and was discharged on June 20, 2024. There was no follow-up information documented in the record at the time of the inspection.
Patient #6 was admitted on August 12, 2024 and was discharged on August 26, 2024. There was no follow-up information documented in the record at the time of the inspection.
This is a repeat citation from the November 14, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will ensure that the follow up calls to discharged patients are completed within 7 days of discharge, as stated in the discharge and aftercare policy. Project director created a report to run in electronic health record, which provides the names of the patients who were discharged in the last seven days. Facility director will run this report throughout the week to ensure that case managers complete the follow up phone calls within the necessary time frame.
This was reviewed with case managers during group supervision on Monday 12/16/24, and facility director will monitor the progress of this each morning when facility director runs the report, as report also indicates if the follow up call was completed or not.
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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 the patient records confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa Code Part V, Chapter 709 in three of seven patient records reviewed.
Patient #2 was admitted on December 6, 2024 and was active at the time of the inspection. There were release of information forms to a treatment provider, a physician, and two different funding sources signed and dated by the patient on December 6, 2024; however, there was no documentation indicating a copy of the release forms were offered to the patient.
Patient #5 was admitted on June 17, 2024 and was discharged on June 20, 2024. There were release of information forms to a community center, an emergency contact, and two different funding sources signed and dated by the patient on June 20, 2024; however, there was no documentation indicating a copy of the release forms were offered to the patient.
Patient #7 was admitted on September 12, 2024 and was discharged on September 18, 2024. There was a release of information form to another treatment provider signed and dated by the patient on September 17, 2024; however, there was no documentation indicating a copy of the release form was offered to the patient.
This is a repeat citation from the November 14, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Releases of information were updated by facility director, to follow DDAP standards. The new releases of information were reviewed with case managers in group supervision on Monday 12/16/24, and with patient care manager in team meeting on 12/16/24. Patient care manager will provide nurses with additional training to complete releases of information as necessary on second/third shift (when case manager is not available to complete release of information), this will occur during upcoming nursing meeting on 1/22/2025. Minutes will be placed in binder on the unit for future reference and review. Facility director will audit 6 charts on a quarterly basis to ensure compliance in this area. |