INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25-27, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare York Pharmacotherapy Services 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure that counseling sessions could not be seen or heard from outside the counseling rooms.
The facility conducts group counseling sessions in the conference room, but the inside window on the rights side of the conference room has no covering, and allows anyone in the hallway to see inside the room.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The facility conducts group counseling sessions in the conference room, but the inside window on the rights side of the conference room has no covering, and allows anyone in the hallway to see inside the room.
The Program Director will ensure the entire window of the conference room, where group sessions are facilitated is covered with a self- adhesive 3D window film. The application of the film, will prevent anyone in the hallway, the ability to see inside of the conference room. The date of completion will be 9/14/18.
Compliance will be monitored by the PD who will ensure the appropriate material is purchased and applied to the conference room window. Proof of covering will be submitted to DDAP via a photograph.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to ensure that it consents to release information complied with 4 Pa. Code 255.5 in two of seventeen applicable client records. 4 Pa. Code 255.5 b restricts the information that can be released to insurance companies to the following five points:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Client #4 was an active client at the time of the on-site inspection. The consent to release information for the client's insurance provider dated May 23, 2108, included authorization to disclose the client's MARS, treatment progress notes, discharge summary and aftercare plan.
Client #17 was an active client at the time of the on-site inspection. The consent to release information for the client's insurance provider dated October 30, 2017, included authorization to disclose the client's MARS, discharge summary, psychosocial assessment and physical.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Facility failed to ensure that it consents to release information complied with 4 Pa. Code 255.5 in two of seventeen applicable client records.
Supervisor will ensure all consents to release information to insurance companies will be restricted to the five points highlighted in the 4 Pa. Code 255.5 only. The Clinical Supervisor will schedule a mini- training for all counselors to review the appropriate completion of all consents forms, in order to be in compliance with Code 255.5. The target date of completion for this training will be 9/15/18.
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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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
The facility failed to notify all patients of their rights.
A total of seventeen patient records were reviewed during the on-site inspection. There were two applicable patient records that did not have written acknowledgement from patients that they had been informed of their rights.
Clients #4 and #11 were not informed of the following patient 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.
(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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(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 as part of the inspection process.
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Plan of Correction
The facility failed to notify all patients of their rights.
The facility failed to notify 2 patients of rights upon admission into the program.
The facility will ensure that identified rights (1,3,4,5 &6) are added to the Patient Rights. These rights will be provided to the patient at time of admission and receipt acknowledgement will be included within the Orientation Checklist. Patient Rights including #1,3,4,5, & 6 will also be displayed within the waiting room at all times.
The clinical and medical team will review modifications made to the Patient's Rights within the following team meeting. Counselors will then be directed to distribute the revised copy of the Patient's Rights to each client. Display of Patient Rights will be ensured by the facility during the physical plant surveys. Changes to Patient Rights will be completed by 9/13/18 and all patients will be informed of revisions by 9/28/18. Compliance will be monitored monthly through open chart reviews completed by the Clinical Supervisor.
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715.16(c)(3)(i-viii) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
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Observations
The facility failed to ensure that the documented number of days determined by the physician for take-home methadone matched the number of take-home doses the patients were given, and the facility failed to ensure that all patients who were receiving take-home methadone were in treatment long enough to qualify for the number of days they were receiving take-home methadone.
Three of seventeen patient records were reviewed for take-home medications.
Patient #12 was admitted for narcotic treatment on July 8, 2016. The patient had an evaluation signed by a narcotic treatment physician dated May 14, 2018, approving four days of take-home methadone, but the patient's record documents that the patient began receiving a six day supply of take-home methadone on May 18, 2018. The patient had not been in treatment for 3 years and was not eligible for four days of take-home methadone or six days of take-home methadone.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
A rescind order was put in place for Patient #12, reducing the take home medication from once weekly to biweekly status. The client is now dosing on site on Mondays and Thursdays, receiving no more than 3 take home bottles at a time. The client was admitted 7/8/2016 and meets all criteria for twice weekly attendance. The facility will continue quarterly call backs to ensure an inventory of the patient's remaining take home medication supply.
Physicians approving take home methadone requests, will ensure the patient is receiving the required amount of take home methadone based on the client's admission date to narcotic treatment. Patient admission date will be verified by the physician prior to approval of take home medication. Following verification of admission date, Physician will approve the take homes by signing the "Request for Take Home Medication" form as well as write an order within the patient file. Physician and Program Director will attest to time in treatment as a criteria for take home medication as verified within the "Request for Take Home Medication." All requests for take home medication will be reviewed weekly within the team meeting. This change in process will begin 8/28/18.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to ensure that it provided the required psychotherapy hours for all of its patients.
A total of eighteen patient records were reviewed during the on-site inspection.
Patient # 10 was admitted for narcotic treatment on September 28, 2018. The patient only received two hours of psychotherapy for the month of June 2018, zero hours of psychotherapy for the month of May 2018 and zero hours of psychotherapy for the month of April 2018.
These findings were reviewed with the fcaility staff as part of the inspection process.
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Plan of Correction
The identified client was been placed on a motivational contract on 5/1/2018 by his/her respective counselor that specifically outlines the psychotherapy requirement and the expectation of compliance. This client was placed on the motivational contract due to failure to attend assigned counseling sessions. This client was later discharged on 5/21/2018 with type of discharge being "Transfer to another methadone maintenance program."
Counselors will maintain a weekly therapy tracking grid for all of their clients. Tracking grids will be reviewed during monthly clinical supervision.
Clients not on track with meeting therapy hours will receive reminder calls of their appointment, be reminded again during check-in, and will have soft holds placed in effort to meet with their counselor.
Compliance of the above will be monitored by the Clinical Supervisor monthly during supervision with counselors.
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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
The facility failed to ensure that it documented a follow up with all discharged patients.
A total of seventeen patient records were reviewed during the on-site inspection.
Patient #9 was admitted for treatment on January 2, 2017, and discharged on May 16, 2018, but there was no documentation of a follow up done on the patient after the patient's discharge.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Supervisor will conduct at least 1 hour of direct service, including clinical documentation review for all counselors requiring direct observation monthly. This will be reported within a supervision note. Supervision notes will be signed off by the counselor and supervisor and kept on site. The Clinical Supervisor will facilitate a mini- training for all counselors on discharge planning, including the requirement of follow up calls within 7 days of discharge. This training is scheduled to take place by 9/15/18.
Compliance will be monitored monthly through open and closed chart reviews completed by the Clinical Supervisor and then submitted to the PD for further review.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to ensure that annual evaluations were completed on all of its patients.
A total of seventeen patient records were reviewed during the on-site inspection.
Patient #8 was admitted for narcotic treatment on March 19, 2015, and was an active patient at the time of the on-site inspection. The patient's annual evaluation dated March 28, 2018, was not signed by the medical director.
Patient #10 was admitted for narcotic treatment on September 28, 2016, and discharged on May 21, 2018. At the time of the patient's discharge the patient had not had an annual evaluation performed.
These findings were reviewed with the facility staff as part of the inspection process.
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Plan of Correction
Counselors will ensure to forward all annual evaluations to the Medical Director only for signature. The Clinical Supervisor will review all clinical documentation during monthly clinical supervision and facilitate open chart reviews. The supervisor's findings will be reported within a supervision note. Supervision notes will be signed off by the employee and the supervisor and kept on site. In addition, the team will review regulations concerning patient annual reviews. Within this meeting, the team will discuss proper notification of staff, requirements for review and signature, and regulatory timeframes. This review will occur within the following team meeting on 9/11/18.
Compliance will be monitored by the PD who will review all supervision notes monthly and then submitted to clinical compliance officers for additional review.
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