INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on July 22-25, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Pyramid Healthcare York Pharmacotherapy 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
During a licensing inspection conducted on June 22-25, 2019, the facility failed to provide documentation of a qualifying degree for employee # 5.
Employee # 5 was hired April 29, 2019 as a counselor and was still in this position at the time of the inspection. At the time of the inspection, the employee had a Doctorate in Philosophy, a Masters in English, and a Bachelors in English, which are non-qualifying degrees for the position of a counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the employee presenting with a non-qualifying degree for the position of counselor, employee was moved from a Counselor to a Counselor Assistant with an acknowledged high school. The employee is scheduled to engage in weekly supervision with the Clinical Supervisor. The employee will only provide direct services when engaging in direct supervision with another employee qualified as Counselor or the Clinical Supervisor. All submitted documentation will be reviewed and signed by the Clinical Supervisor at a minimum. Exception has been requested based on her experience. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
During a licensing inspection conducted on July 22-25, 2019, the facility failed to provide documentation of fire drills being conducted during normal staffing conditions. Eight of the Twelve fire drills were conducted when clients were no longer present in the building and after operation of dosing times.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review Fire Drill Procedures with York County Maintenance Supervisor prior to September 15, 2019 regarding conducting fire drills at different times of the day.
Program Director to monitor quarterly to ensure ongoing compliance. |
709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
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Observations
During a Project Wide review of Policy and Procedures, the facilities Client Rights policy was missing - sex and marital status in 709.30 (2), and Reasons for removing sections shall be documented in the record in 709.30 (3).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual will be updated by the Policy and procedure committee to include sex and marital status in section 709.30. Chief Compliance Officer will ensure completion of policy by Sept 1, 2019. The program director will be responsible to ensure that the new policy is shared with all staff by Sept 15, 2019. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
During a licensing inspection conducted on July 22-25, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in patient record # 2.
Patient # 2 was admitted on August 13, 2018 and was still active at the time of the inspection. A letter addressed to a government agency dated June 10, 2019 provided information on the status of the patient ' s employment.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility failed to ensure to keep disclosures of client identifying information within 4 Pa. Code 255.5 in one client record.
Client was made aware of the over disclosure and decided to remove the letter from the record. The letter included within the client record disclosing information outside of 4 Pa. Code 255.5 was subsequently removed entirely from the chart. Clinician and client updated the official consent. Supervisor will ensure all client identifying information disclosed is restricted to the five points highlighted in the 4 Pa. Code 255.5 only.
Compliance will be monitored monthly through open chart reviews completed by the Clinical Supervisor and then submitted to the PD for further review. Staff will review 4 Pa. Code 255.5 within an upcoming staff meeting to ensure understanding the proper release of information.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
During a licensing inspection conducted July 22-25, 2019, the project failed to provide documentation that the client was notified of their rights in seven of fourteen client records reviewed. Clients are provided a handbook to include client rights. The handbook does not contain:
709.30 (3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The new form to be added to Carelogic for all programs by September 1, 2019. Program Director will ensure all staff are educated on the new form by September 15, 2019. Client handbook will be updated and re-distributed to all active clients. Updated versions will also be available in the front lobby.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on July 22-25, 2019, the project failed to provide documentation of an unusual incident report requiring the presence of police, fire or ambulance personnel being filed with the department within three business days.
An incident dated January 21, 2019 that required fire department presence was not reported to the Department.
An incident dated August 21, 2018 that required police presence was not reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each unusual incident will require the Program Director to complete an Unusual Incident Report. This report will subsequently be sent to the the Department of Drug and Alcohol Programs for review. A copy of the incident will be kept in a record log to review annually. A copy verifying completed transmission to DDAP will be kept alongside the Unusual Incident Report to review annually. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
During a licensing inspection conducted on July 22- 25, 2019, the facility failed to provide documentation of a case consultation at least quarterly during the patients first year as stipulated in the Projects Policy and Procedure Manuel.
Patient # 4 was admitted on November 12, 2018 and was still active at the time of the inspection. The only case consult documented occurred on July 24, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based off client records reviewed, the facility failed to demonstrate completion of case consultations within a patient's record.
All counselors will ensure that clinical records include case consultations on each client active within the program. Case consultations will be completed quarterly during the patient's first year and at any time there is a change in course of treatment. Case consultations within the clinical record will be signed by the primary counselor and at least two clinical reviewers.
Compliance will be monitored monthly through open chart reviews completed by the Clinical Supervisor and then submitted to the PD for further review.
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