INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 17, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from July 2021 through July 2022, the facility failed to conduct unannounced fire drills at least monthly as there was no unannounced drill in March 2022.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Risk Manager at the site will ensure that unannounced fire drills happen and are on a monthly basis. Risk Manager will set a reminder on her calendar monthly to run the fire drill and ensure it is unannounced. Risk Manager will documented in the Fire Drill Log.
Executive Director will complete monthly audits on the Fire Drill log to ensure completion.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from July 2021 through July 2022, the facility failed to prepare alternative exit routes in the July 2021 through May 2022 and in July 2022 as the front door was used in these drills.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Risk Manager at the site will ensure that unannounced fire drill will happen monthly with the alternating use of all available fire exits. Risk Manager will ensure by using the fire drill log that alternative exits are used in random to provide proper examples of all exit routes for staff and clients.
Exit routes will be documented in the Fire Drill log. Executive Director will complete monthly audits on the log to ensure completion of different exits being utilized.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to conduct random urinalysis at least monthly on two out of nine records reviewed.
Patient #1 was admitted on June 30, 2022 and was still active at the time of the inspection. A random urinalysis was not conducted in July 2022.
Patient #2 was admitted on October 27, 2021 and discharged on February 8, 2022. A random urinalysis was not conducted in November 2021.
This is a repeat citation from the August 26, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Nursing staff will generate a drug screen report in the Methasoft EMR system on the 1st of each month in order to set up a client UDS schedule on a day that the client is scheduled to come into the facility for dosing.
In addition to the generated report from Methasoft, nursing will run an Active Client Report on all new admits for the last week of the previous month and schedule those clients for a urine drug screen within this month to ensure they are not missed be the generated system.
A flag will be added in Methasoft to prompt the nurse to give a UDS on the client's scheduled day. If a client's take home status changes during the month, the nurse will put a flag in Methasoft to initiate a new UDS date. If client does not show on date of scheduled UDS, nurse will put a flag in Methasoft for the next scheduled day to insure completion of required monthly UDS.
Executive Director will review monthly any discrepancies between the generated report and the manual active client list to ensure everyone is scheduled and as a checks and balances
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715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
Based on observation conducted of the urinalysis process during the onsite inspection, the facility failed to ensure that the urine collection was unaltered as staff did not watch the monitors during the process for two patients.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All nursing staff will be re-trained on the 715 regulations and methadone dosing expectations. Training will occur on 9/27/2022 with the Executive Director.
The nurse who is dosing the client and responsible for the urine will provide the client the urine drug screen cup, stop and observe the client's urine screen until the cup is sealed by the client and placed in the tray pass. Nurse will not accept another client at dosing window until full observation is completed on the urine screen.
Clinical Supervisor will complete Monthly audit checks on nursing staff completing the observation processes for urine drug screens. Clinical Supervisor will keep a log of all audits and review with medical staff in supervision if processes are not being followed.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the observation of medication administration, the facility failed to ensure each patient ingested the agent by having them speak afterwards in three patients. In addition, one patient was observed on their cell phone during medication administration, which is not permitted in section 715.17C - 11 of the facility's policy and procedures manual.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director reviewed regulation 715.17 with nursing staff on 9/27/2022. We will review the importance of both the nurse and the client giving the undivided attention during the dosing process at all times. This including the client being attentive and not pro-occupied.
Nursing staff will be trained to ask all clients to "please open mouth" to ensure proper dispensing and consumption of medication.
In additional, all nurses will trained in redirecting clients to put their phone away at the dosing window. Any client who is observed on the phone will be asked to leave the dosing window until their call is complete and will not be dosed until we have the client undivided attention.
Clinical Supervisor will complete Monthly audit checks on nursing staff completing the process of ensuring clients ingested medication and that no distractions are occurring at dosing window. Clinical Supervisor will keep a log of all audits and review with medical staff in supervision if processes are not being followed.
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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
Based on a review of patient records, the facility failed to provide 2.5 hours of psychotherapy per month during the patient's first two hours in six out of seven records reviewed.
Patient #1 was admitted on June 30, 2022 and was still active at the time of the inspection. In July 2022, the client had 60 minutes of individual therapy and one no show appointment for a sixty-minute individual session.
Patient #2 was admitted on October 27, 2021 and discharged on February 8, 2022. In December 2021, the client had sixty minutes of individual therapy and one no show appointment for a sixty-minute individual session.
Patient #5 was admitted on January 24, 2022 and discharged on July 7, 2022. In March 2022, the client had one sixty-minute individual session. In April 2022, the client had individual sessions totaling two hours and 15 minutes. There were no documented sessions in May 2022.
Patient #6 was admitted on November 16, 2021 and was still active at the time of the inspection. In April 2022, the client had forty minutes of therapy. In May 2022, the client had 30 minutes of therapy. There were no documented sessions in June 2022.
Patient #7 was admitted on January 23, 2020 and discharged on March 14, 2022. In December 2021, the client received one hour and ten minutes of therapy. In January and February 2022, there was no documented sessions with one sixty minute no show occurring in each month.
Patient #8 was admitted on June 10, 2021 and was still active at the time of the inspection. In May 2022, the client received one and a half hours of therapy.
This is a repeat citation from the August 26, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will train all clinical staff on the regulation of needing 2.5 hours of psychotherapy per month in the first 2 years and 1 hour being individual treatment.
All staff will be trained on setting up next individual appointments on the EMR schedule prior to leaving their current appointment. Staff will also be trained in how to set clients up on group rosters to ensure they are scheduled for the 2.5 hours per month of treatment required in the first 2 years. Staff will receive a refresher training on how to status all group rosters, complete notes and reach out to clients for no show attendance. Alerts will be placed in the Methasoft system to stop clients before dosing to reschedule for group or individual sessions.
Training and review will take place on 9/14/2022 by the Executive Director and Clinical Supervisor.
Rosters and correct scheduling will be in place by 9/26/2022.
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715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document the transfer of patient files to the patient's new facility in two out of two applicable records reviewed.
Patient #2 was admitted on October 27, 2021 and discharged on February 8, 2022.
Patient #5 was admitted on January 24, 2022 and discharged on July 7, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors/ Lead Counselor and Clinical Supervisor who oversees the guest dosers/ transfers will be trained on the process of getting confirmation from the transfer facility to put into our EMR system. If we are unable to get confirmation from the facility it will be reviewed that we will place confirmation E-Fax into the client's EMR chart in the document library to show proof of sending.
Clinical Supervisor, Lead Counselor and Regional Quality Management team will audit guest dosing/ transfer charts for all of those they oversee monthly to ensure we have confirmation documentation present.
Training will take place on 9/14/2022.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document the notification to the patient's previous facility of the admission and date of the initial dose administered in one out of one applicable record.
Patient #6 was admitted on November 16, 2021 and was still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors/ Lead Counselor and Clinical Supervisor who oversees the guest dosers/ transfers will be trained on the process of sending a dose verification form to the home clinic to provide proof that we received the information and have admitted the client. Facility will be reviewed that we place confirmation E-Fax into the client's EMR chart in the document library.
Clinical Supervisor, Lead Counselor and Regional Quality Management team will audit all guest dosing/ transfer charts for all of those they oversee monthly to ensure we have confirmation documentation present.
Training will take place on 9/14/ 2022.
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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
Based on a review of patient records, the facility failed to conduct an annual clinical evaluation in two out of four applicable records.
Patient #7 was admitted on January 23, 2020 and discharged on March 14, 2022. The most recent annual evaluation was due no later than January 23, 2022; however, it was not documented as of the date of discharge.
Patient #8 was admitted on June 10, 2021 and was still active at the time of the inspection. The annual evaluation was due no later than June 10, 2022; however, it was not documented as of the date of the inspection.
This is a repeat citation from the August 26, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director and Clinical Supervisor will re-train all staff on how to run the Methasoft Annual Clinical Report available to them. This report generates annual reports needed at the 1st of the month for annuals due that month.
All staff will be required to run this report the Monday before the first of the next month and cross check this with their active caseload to then complete the Annual review.
Executive Director and Clinical Supervisor will review with staff the expectation of running this report on and completing the Annual reports as required.
Clinical Supervisor and Lead Counselor will run this report monthly on all staff they oversee and then audit charts to ensure that these annual reports are completed in full.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of eight records reviewed.
Patient #2 was admitted on October 27, 2021 and discharged on February 8, 2022. A treatment plan was completed on November 8, 2021 and the update was due no later than January 8, 2022; however, no update was documented in the record by the discharge date.
Patient 3 was admitted on August 12, 2019 and was still active at the time of the inspection. A treatment plan update was completed on October 28, 2021 and the next update was due no later than February 28, 2022; however, it was not completed until March 4, 2022.
Patient #5 was admitted on January 24, 2022 and discharged on July 7, 2022. A treatment plan update was completed on April 15, 2022 and the next update was due no later than June 15, 2022; however, it was completed on June 23, 2022.
Patient #8 was admitted on June 10, 2021 and was still active at the time of the inspection. A treatment plan update was completed on October 20, 2021 and the next update was due no later than December 20, 2021; however, it was completed on January 11, 2022. The next update was due no later than March 11, 2022; however, it was completed on May 9, 2022. There were no more documented updates in the patient's record.
This is a repeat citation from the August 26, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director and Clinical supervisor will review regulations regarding treatment plans and treatment plan updates with clinical team and reinforce expectation of timely review and completion of documentation. Review will take place on 9/14/2022.
Clinical supervisor and lead counselor will monitor counselor alerts for upcoming treatment plan reviews in the electronic health record system and follow-up with counselor to ensure timely completion of updates.
Treatment plan updates will be reviewed by clinical supervisor and lead counselor during supervision and during monthly chart audits. Counselors will be required to bring case tracker to supervision with documentation that tx plans were completed and if not completed proof of clients missed appointment and attempted reach out.
DNS appointments in system and call/reach out attempts in system/ put a stop dose in Methasoft to schedule appointment
Audits for this will happen monthly and be reviewed with staff individually in supervisions.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of patient records, the facility failed to ensure that the patients received counseling services according to their individual comprehensive treatment plan in six out of nine records reviewed.
Patient #2 was admitted on October 27, 2021 and discharged on February 8, 2022. A treatment plan dated November 8, 2021 indicated monthly group sessions. There were no documented group sessions in December 2021.
Patient #5 was admitted on January 24, 2022 and discharged on July 7, 2022. A treatment plan dated February 16, 2022 indicated individual monthly sessions. There were no documented individual sessions in May 2022.
Patient #6 was admitted on November 16, 2021 and was still active at the time of the inspection. A treatment plan dated May 13, 2022 indicated individual monthly sessions. There were no documented individual sessions in June 2022.
Patient #7 was admitted on January 23, 2020 and discharged on March 14, 2022. Two treatment plans dated October 5, 2021 and December 7, 2021 indicated group sessions monthly. There were no documented group sessions in December 2021 through February 2022.
Patient #8 was admitted on June 10, 2021 and was still active at the time of the inspection. Two treatment plans dated January 11, 2022 and May 9, 2022 indicated group sessions monthly. There were no documented group sessions in May through July 2022.
Patient #9 was admitted on September 19, 2017 and was still active at the time of the inspection. The May 3, 2022 treatment plan indicated monthly individual and group sessions. There were no documented individual sessions in June 2022. In addition, there were no group sessions in March through July 2022.
This is a repeat citation from the August 26, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will re-train all clinical staff on the regulation that clients are receiving counseling services according to their individualized treatment plan.
All staff will be trained on setting up next individual appointments on the EMR schedule prior to leaving their current appointment and in accordance with their treatment plan.
Staff will also be trained in how to set clients up on group rosters to ensure they are scheduled for their group needs based on their individualized treatment plan. Staff will receive a refresher training on how to status all group rosters, complete notes and reach out to clients for no show attendance. Alerts will be placed in the Methasoft system to stop clients before dosing to reschedule for group or individual sessions.
Regional Quality Management team will continue monthly audits in this area and review in out monthly meeting with leadership team.
Training with the staff will take place on 9/14/2022 by the Executive Director and Clinical Supervisor.
Rosters and correct scheduling will be in place by 9/26/2022.
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