INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 10, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Millcreek Community 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 and a plan of correction is due on February 10, 2011.
|
Plan of Correction
|
157.4 LICENSURE Director of drug and alcohol services.
157.4 Director of drug and alcohol services.
When a hospital provides inpatient drug and alcohol detoxification services or inpatient drug and alcohol detoxification and treatment and rehabilitation services, there shall be a director of the drug and alcohol services who is responsible for the planning, organization, implementation, and management of the services and is qualified to perform these functions by education and experience.
|
Observations
Based on the review of the facility director's personnel record, the facility failed to hire a facility director who was qualified to perform the functions of a facility director.
The findings include:
The personnel record for the facility director was reviewed on January 10, 2011. The facility director failed to meet the qualifications as defined in 704.5 (c). The facility director is a diploma registered nurse, which is a credential that does not meet the degree requirements identified in the regulation.
|
Plan of Correction
The title of Project/Facility Director will be held by the President/CEO of Millcreek Community Hospital who meets all of the requirements set forth in the regulations. The effective date of this change was 1/21/2011. |
157.23 (a) LICENSURE Patient records.
157.23 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.
|
Observations
Based on the review of patient records, the facility failed to document follow-up information in the patient's medical record in two of two patient records.
The findings include:
Six patient records were reviewed on January 10, 2011. Two patient records required follow-up information. Per facility policy, follow-up is to be completed at four weeks. Follow-up information was not documented in patient records # 4 and 6.
Patient # 4 was admitted on July 9, 2010 and discharged on July 14, 2010. Follow-up was due by August 14, 2010. There was no documentation that a follow-up had been attempted.
Patient # 6 was admitted on November 28, 2010 and discharged on December 3, 2010. Follow-up was due by January 3 , 2010. There was no documentation that a follow-up had been attempted.
|
Plan of Correction
Review of requirements relating to aftercare and follow-up documentation will be completed by Nursing Administration/Designee to all Detox staff.
An Aftercare/Follow-up log has been created in order for staff to document timely follow-up information after discharge.
Staff will be inserviced on the use of the log by Nursing Administration/Designee by 02/14/11
An audit of the log book on a monthly basis will be completed verifying that all follow up letters were sent timely. This will be the responsibility of the Director of Patient Care Services.
|