INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone/buprenorphine monitoring inspection. The inspection was conducted on November 20-21, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite 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 the inspection:
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of eleven personnel and training records on November 20-21, 2017, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of one personnel record reviewed.
Employee # 3 was hired at the project on April 14, 2015 and was promoted to the position of clinical supervisor on August 5, 2016. Monthly supervision meetings were required to take place from August 2016 through January 2017. There was no documentation of monthly supervision meetings in the personnel record of employee # 3 for November 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Monthly supervision notes for the clinical supervisor who required monthly supervision meetings for the first 6 months were reviewed and the facility failed to demonstrate that this occurred monthly.
Supervisor will ensure that at least 1 monthly meeting of supervision occurs for all clinical supervisors within their first 6 months to discuss duties and overall performance. This will be reported within a supervision note. Supervision notes will be signed off by the employee and supervisor and kept on site.
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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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of nine patient records on November 20-21, 2017, the narcotic treatment program failed to maintain a complete initial physical examination at the time of intake, in one of nine patient records.
Patient #2 was admitted to treatment on June 28, 2017. During the intake process, patient #2 had a physical examination on July 3, 2017. The medical director neglected to document vital signs taken during the physical examination for Patient #2 on July 3, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility failed to document full medical examination, including vital signs, at time of a patient admission.
Physician completing the admission medical exam will ensure that all medical examinations are properly documented within the medical chart including vital signs. Physician will ensure to sign off on this procedure at completion of admission.
Compliance will be monitored through peer reviews of all medical charts. These will be completed monthly to ensure compliance of all initial and annual physical examinations and their appropriate documentation.
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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
Based on a review of nine patient records on November 20-21, 2017, the narcotic treatment program failed to maintain a complete patient file containing a case consultation, in one of nine patient records reviewed.
Patient #2 was admitted to treatment on June 28, 2017 and discharged on 11-2-17. The facility failed to document that a case consultation regarding the patient was held during his treatment.
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 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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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of nine patient records on November 20-21, 2017, the narcotic treatment program failed to maintain a complete patient file containing a psychosocial evaluation of the patient, in one of nine patient records reviewed.
Patient #2 was admitted to treatment on June 28, 2017 and discharged on 11-2-17. The facility failed to document that a psychosocial evaluation was completed for the patient during his treatment.
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 the psychosocial evaluation within a patient's record.
All counselors will ensure that clinical records include psychosocial evaluations on each active client. Psychosocial evaluations will be completed during the patient's first 30 days and reviewed during any change in course of treatment. Psychosocial evaluations within the clinical record will be signed by the primary counselor.
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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715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of nine patient records on November 20-21, 2017, the narcotic treatment program failed to prepare a treatment plan that outlined realistic short and long-term treatment goals that are mutually acceptable to the patient and the program, in one of nine patient records reviewed.
Patient #2 was admitted to treatment on June 28, 2017 and discharged on 11-2-17. The facility failed to document a comprehensive treatment plan developed with the patient which identifies goals and action steps, type and frequency of treatment, and support services while in treatment.
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 a comprehensive treatment plan that outlined goals and action steps towards recovery planning within a patient's record.
All counselors will ensure that clinical records include a comprehensive treatment plan which identifies goals and actions steps towards recovery planning following admission into the program. This document will show mutual acceptance by the patient and the program through required signatures of the patient, primary counselor, clinical supervisor and physician. Treatment plan updates will be completed and reviewed minimally every 60 days or during a change in the course of treatment.
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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