INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 26, 2021 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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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
Based on an observed medication administration the facility failed to maintain confidentiality of all client identities as clients were observed throwing away take home bottles without blacking out each name and dose into a trash can.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The executive director reviewed confidentiality procedures in crossing off client names on empty take home bottles with all dosing nurses. This took place on 9/13/21. Nurses will insure that black sharpies are available to clients at all dosing windows at the start of each shift. Executive Director will perform unannounced, bi-monthly, documented audits of returned take home bottles to insure confidentiality is being followed. This will begin on October 1, 2021. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of the physician timesheets for the months of April, May, June, and July 2021, the facility failed to provide physician services at least one hour per week, onsite for every ten patients during the month of April, June and July.
During the week of April 4-10, 2021, the patient census was 543. The facility was required to provide at least 54.3 physician hours. There were only 47 physician hours documented.
During the week of June 6-11, 2021, the patient census was 532. The facility was required to provide at least 53.2 physician hours. There were only 45 physician hours documented.
During the week of July 18-24, 2021, the patient census was 527. The facility was required to provide at least 52.7 physician hours. There were only 22 physician hours documented.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Medical Director and CRNP will be given the client census every Monday by the clinical supervisor so hours can be scheduled accordingly to meet the requirement. Arrangements will be made in advance for coverage for extended physician or CRNP hours due to vacations through a LOCUM agency or Pyramid program in order to meet the requirement. Coverage to meet hours will be set up by executive director and regional director. Executive director will be responsible for checking hours v. census on a weekly basis. This will begin in October 1, 2021. |
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 seven patient records, the facility failed to obtain and document a random urinalysis monthly in two patient records.
Patient record #6 was admitted on February 15, 2017 and was discharged on March 9, 2021. The patient record did not include documentation for a urine drug screen in December 2020.
Patient record #7 was admitted on October 16, 2014 and was discharged August 17, 2021. The patient record did not include documentation for a urine drug screen for the months of November 2020, April 2021 and May 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Nursing will generate a random drug screen report in the Methasoft EMR 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. If clients fall on the last day of the month, the nurse will reschedule those clients for earlier in the month as a precaution in case the clients are unable to dose the last day of the month. 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. This will begin on October 1, 2021.
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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 nine patient records, the facility failed to provide three patients with 2.5 hours of psychotherapy per month during the patient ' s first 2 years of treatment.
Patient # 2 was admitted on October 24, 20219 and still active at the time of the inspection. In March 2021, the patient received 0 hours of therapy. In May 2021, the patient had 1 hour of individual therapy and 0 hours of group therapy. In June 2021, the patient received 0 hours of therapy and in July 2021 the patient received 2 hours of individual therapy and 0 hours of group therapy.
Patient #3 was admitted on May 25, 2021 and was still active at the time of the inspection. In June 2021, the patient received 1 hour of individual therapy and 0 hours of group therapy and in July 2021 the patient received 1 hour of individual therapy and 0 hours of group therapy.
Patient #5 was admitted on August 30, 2018 and was discharged on April 29, 2021. The patient only received 1 hour of individual psychotherapy hours for the months of January 2021, February 2021, March 2021, and April 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
All clinical staff will be required to keep a caseload tracker and update this tracker on a weekly basis. This tracker will include tracking treatment plan updates/ completion, individual sessions scheduled/completed, group sessions scheduled/completed, case consults due/completed, and annual reviews due/completed. Clinical staff will review tracker weekly and engage non-compliant 2.5 hour clients. Clinical supervisor and lead counselor will train clinical staff and implement case tracker by 10/15/21. Caseload trackers will be reviewed by clinical supervisor and lead counselor during monthly supervision with clinical staff to ensure clients are meeting counseling requirements. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of seven patient records, the facility failed to provide one patient with 1 hour of psychotherapy per month during the patient ' s third and fourth year of treatment.
Patient #4 was admitted on July 14, 2017 and was still active at the time of the inspection. The patient only received 30 minutes of individual therapy during the months of January 2021, February 2021, April 2021 and August 2021. The patient received 0 hours of psychotherapy during May 2021, June 2021 and July 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
All clinical staff will be required to keep a caseload tracker and update this tracker on a weekly basis. This tracker will include tracking treatment plan updates/ completion, individual sessions scheduled/completed, group sessions scheduled/completed, case consults due/completed, and annual reviews due/completed. Clinical staff will review tracker weekly and engage non-compliant 1 hour clients. Clinical supervisor and lead counselor will train clinical staff and implement case tracker by 10/15/21. Caseload trackers will be reviewed by clinical supervisor and lead counselor during monthly supervision with clinical staff to ensure that clients are meeting counseling requirements. |
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 seven patient records, the facility failed to document an annual clinical evaluation of the patient in one patient record reviewed.
Client #1 was admitted on December 26, 2018 and was still active at the time of the inspection. The most recent annual evaluation was due no later than January 2, 2021; however, it was not documented as of the date of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
All clinical staff will be required to keep a caseload tracker and update this tracker on a weekly basis. This tracker will include tracking treatment plan updates/ completion, individual sessions scheduled/completed, group sessions scheduled/completed, case consults due/completed, and annual reviews due/completed. Clinical staff will review tracker weekly and engage all non-compliant clients. Clinical supervisor and lead counselor will train clinical staff and implement case tracker by 10/15/21. Caseload trackers will be reviewed by clinical supervisor and lead counselor during monthly supervision with clinical staff to ensure that all annual reviews are completed for that month by checking caseload tracker and annuals due report in Methasoft.
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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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three client records reviewed.
Client #2 was admitted on August 30, 2018 and was still active at the time of the inspection. A treatment plan update was completed on September 9, 2020 and the next update was due no later than November 9, 2020; however, there was no update documented in the record until May 25, 2021.
Client #4 was admitted on July 14, 2017 and was still active at the time of the inspection. A treatment plan update was completed on April 24, 2020 and the next update was due no later than August 24, 2020; however, there was no update documented in the record until September 17, 2020.
Client #6 was admitted on February 15, 2017 and was discharged on March 9, 2021. A treatment plan update was completed on March 13, 2020 and the next update was due no later than July 13,2020; however, there was no update documented in the record until August 28, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
All clinical staff will be required to keep a caseload tracker and update this tracker on a weekly basis. This tracker will include tracking treatment plan updates/ completion, individual sessions scheduled/completed, group sessions scheduled/completed, case consults due/completed, and annual reviews due/completed. Clinical staff will review tracker weekly and engage all non-compliant clients. Clinical supervisor and lead counselor will train clinical staff and implement case tracker by 10/15/21. Caseload trackers will be reviewed by clinical supervisor and lead counselor during monthly supervision with clinical staff to ensure treatment plans are being completed in the required timeframes. |
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 seven client records, the facility failed to ensure that all counseling services are provided according to the individual treatment and rehabilitation plan in four records reviewed.
Client #1 was admitted on December 26, 2018 and was still active at the time of the inspection. A treatment plan update completed on January 26, 2021 indicated one individual monthly and one group session monthly. The client ' s record of service and progress notes indicated that the client has not received a group session since September 2020.
Client #2 was admitted on October 24, 2019 and was still active at the time of the inspection. A treatment plan update completed on February 8, 2021 indicated one individual session and one on group session a month. The client ' s record of service and progress notes indicated that the client has not received a group session since December 11, 2019.
Client #3 was admitted on May 25, 2021 and was still active at the time of the inspection. A treatment plan update completed June 25, 2021 indicated individual sessions biweekly and group sessions monthly. The client ' s record of service and progress notes indicated that the client has not received any group session since being admitted.
Client #5 was admitted on August 30, 2018 and was discharged on April 29, 20212. A treatment plan update completed January 8, 2021 indicated individual sessions weekly and group sessions monthly. The client ' s record of service and progress notes indicated that the client has not received any group sessions.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Caseload trackers will be used to monitor client compliance with required 2.5 or 1 hour counseling services to ensure compliance with treatment plan. . Clinical supervisor and lead counselor will train clinical staff and implement case tracker by 10/15/21. Caseload trackers will be reviewed by clinical supervisor and lead counselor during monthly supervision with clinical staff to ensure client counseling hours are matching treatment plans.
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