INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on November 29 through December 2, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc. was found to be not 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report, a review of staff records and a conversation with the facility staff, the facility failed to ensure that staff person #7 received the required trainings.
Employee #3, a lead counselor, was hired on 4/14/15 and was required to obtain 6 hours of HIV/Aids training by 4/14/16. The HIV/Aids training was not completed until 10/4/16.
Employee #7, a counselor, was hired on 10/26/15 and was required to obtain 4 hours of TB/STD training by 10/26/16. The TB/STD trainings were not documented as of the date of the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Human Resource Coordinators will monitor employee's personnel files quarterly to assure 100% compliance with minimum training requirements. Employee 3 has already obtained the training needed, and Employee 7 is scheduled to attend the next available training needed. Compliance will be by 2/28/17. |
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
Based on a physical plant inspection conducted on December 2, 2016 and conversations with facility staff conducted from November 29 through December 2, 2016, the facility failed to ensure privacy of counseling sessions.
The Security room, which is frequently used by staff to meet with clients who do not have scheduled appointments but wish to speak briefly to a therapist, had an uncovered window which allowed unobstructed visual access from the outside of the facility into the room.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Program Director will inform all staff that clients are not permitted to access the security office. No clinical interaction will take place in that location due to confidentiality concerns. Door to security office has been marked "Staff Only" and remains locked. Compliance will be achieved by 1/15/17.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report, a review of staff records and a conversation with the facility staff, the facility failed to provide an annual performance evaluation for staff person #5.
Employee #5, a lead counselor, was hired on 5/28/15.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Human Resource Coordinators will monitor employee's personnel files quarterly to assure 100% compliance with employees being provided annual performance evaluations. Upon further investigation Employee #5 received her annual evaluation from the Clinical Supervisor yet it was incorrectly marked as a 90 day evaluation. Correction has been made. Compliance will be achieved by 11/28/2016 |
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
Based on a review of client records and a conversation with facility staff conducted from 11/29/16 thru 12/2/16, the facility failed to obtain informed and voluntary consent forms in client records #16, 18, 20, 21, 22, 24 & 25.
Client #16 was admitted on 1/12/16 and was discharged 7/1/16. A consent to release form, dated 1/12/16, to a government agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #18 was admitted on 5/16/16 and was discharged 8/22/16. A consent to release form, dated 5/23/16, to a government agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #20 was admitted on 5/19/16 and was discharged 8/31/16. A consent to release form, dated 5/17/16, to a government agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #21 was admitted on 5/19/16 and was discharged 8/11/16. A consent to release form, dated 5/2/16, to a government agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #22 was admitted on 7/13/16 and was discharged 9/20/16. A consent to release form, dated 7/25/16, to a government agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #24 was admitted on 4/4/16 and was discharged 6/1/16. A consent to release form, dated 4/4/16, to a government agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #25 was admitted on 1/28/16 and was discharged 4/7/16. A consent to release form, dated 1/28/16, to a government agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent, including acknowledgement that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 2017. Completion of training will be verified by posttest completion and monitored by Human Resources Coordinators. Clients # 16,18,20,21,22,24, and 25 were not able to be corrected since they had already been discharged. Compliance will be achieved by 2/1/2017 |
715.9(d) LICENSURE Intake
(d) A narcotic treatment program shall explain to each patient treatment options; pharmacology of methadone, LAAM and other agents, including signs and symptoms of overdose and when to seek emergency assistance; detoxification rights; grievance procedures; and clinic charges, including the fee agreement signed by the patient.
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Observations
Based on a review of client records, and a conversation with facility staff, the facility failed to document an informed consent to treatment with buprenorphine in one applicable client record.
Client #19 was admitted on 7/18/16 and discharged on 9/29/2016.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will ensure staff is retrained on documentation of consents to treatment with buprenorphine. This will be monitored through monthly chart audits. Compliance will be achieved by 1/31/2017 |
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 client records, and a conversation with facility staff, the facility failed to document an initial urine screen in one applicable client record.
Client #17 was admitted on 6/9/16 and discharged on 9/16/2016. The first buprenorphine dose was administered on 6/15/16 but the initial urine screen was not documented until 6/22/16.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will ensure staff is retrained on the proper intake procedure around intake drug screens. This will be monitored through monthly chart monitors. Compliance will be achieved by 1/31/17 |
715.18(a)(1) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(1) HIV education services.
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Observations
Based on a review of administrative paperwork, a list of the facility's service agreements and a conversation with facility staff, the facility failed to provide or document agreements for HIV education services.
The agreement between the facility and an outside agency went in to effect on 11/5/2012 and was valid for two years. No current agreement was available at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will ensure service agreements are updated for appropriate service providers, specifically HIV education services.
Service agreement book will be reviewed annually for updates or changes. Compliance will be achieved by 1/31/17.
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717.18(a)(2) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(2) Employment services.
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Observations
Based on a review of administrative paperwork, a list of the facility's service agreements and a conversation with facility staff, the facility failed to provide or document agreements for employment services.
The agreement between the facility and an outside agency went in to effect on 3/30/2012 and was valid for two years. No current agreement was available at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will ensure service agreements are updated for appropriate service providers, specifically employment related services.
Service agreement book will be reviewed annually for updates or changes. Compliance will be achieved by 1/31/17.
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715.18(a)(3) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(3) Adult educational services.
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Observations
Based on a review of administrative paperwork, a list of the facility's service agreements and a conversation with facility staff, the facility failed to provide or document agreements for Adult educational services.
The agreement between the facility and an outside agency went in to effect on 5/29/2012 and was valid for two years. No current agreement was available at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will ensure service agreements are updated for appropriate service providers, specifically adult educational services.
Service agreement book will be reviewed annually for updates or changes. Compliance will be achieved by 1/31/17
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715.18(a)(4) LICENSURE Rehabilitative services
a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(4) Behavioral health services
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Observations
Based on a review of administrative paperwork, a list of the facility's service agreements and a conversation with facility staff, the facility failed to provide or document agreements for behavioral health services.
The agreement between the facility and an outside agency went in to effect on 6/11/2012 and was valid for two years. No current agreement was available at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will ensure service agreements are updated for appropriate service providers, specifically behavioral health services.
Service agreement book will be reviewed annually for updates or changes. Compliance will be achieved by 1/31/17
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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 client records, and a conversation with facility staff, the facility failed to provide documentation of 2.5 hours of psychotherapy in one applicable client record.
Client #13 was admitted on 2/12/16 and was an active client at the time of the licensing inspection. Client treatment plan and record of service indicated client received only 1 hour of psychotherapy per month during his first 5 months at the facility.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will ensure staff is retrained on the required amount of psychotherapy services hours to be provided, specifically the minimal number of hours the client needs to obtain. This will be monitored by monthly chart audits. Compliance will be achieved by 1/31/17. |
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 client records, and a conversation with facility staff, the facility failed to document that it notified a transferring facility of the admission of the patient and the date of the first dose at the facility.
Client #4 was admitted on 7/11/2016 as a transfer from another NTP, and received their first dose on 7/13/16.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will ensure staff is retrained in the proper procedure of documenting notification of transfer paper work, when a client is transferring narcotic treatment programs, specifically written notification the transferring or receiving program, admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program. Compliance will be monitored with monthly chart audits. Compliance will be achieved by 1/31/17.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of client records, and a conversation with facility staff, the facility failed to document an annual physical examination in one applicable client record.
Client #7 was admitted on 11/12/2013 and discharged on 7/19/2016. An annual physical was due by 11/12/2015 but was not documented in the record.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will ensure medical staff is retrained on the completion and documentation for annual physical examinations. Compliance will be monitored through monthly chart monitors. Compliance will be achieved by 1/31/17. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, and a conversation with facility staff, the facility failed to document a psychosocial evaluation at intake in five applicable client record.
Client #14 was admitted on 1/14/16 and was an active client at the time of the licensing inspection.
Client #17 was admitted on 6/9/16 and was discharged on 9/16/16. The psychosocial evaluation was completed on 9/26/16.
Client #21 was admitted on 5/19/16 and was discharged on 8/11/16. The psychosocial evaluation was completed on 10/14/16.
Client #22 was admitted on 7/13/16 and was discharged on 9/20/16. The psychosocial evaluation was completed on 8/23/16.
Client #23 was admitted on 3/22/16 and was discharged on 10/5/16. The psychosocial evaluation was completed on 9/20/16.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Program Director will ensure staff is retrained on the timely completion of the psychosocial evaluations. Compliance will be monitored through staff supervisions and monthly chart reviews.
Compliance will be achieved 1/31/17.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and a conversation with the facility staff, conducted from 11/29/16 thru 12/2/16, the facility failed to document a preliminary treatment plan in client record # 20.
Client #20, who received buprenorphine, was admitted on 5/19/16 and was discharged 8/31/16.
This information was discussed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure staff is retrained on proper procedure of intake paperwork specifically as it pertains to the preliminary treatment plan and the timeframes for completion. Compliance will be monitored through monthly chart reviews. Compliance will be achieved by 1/31/17. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and a conversation with the facility staff, conducted from 11/29/16 thru 12/2/16, the facility failed document a treatment plan in client record #12.
Client #12 was admitted on 7/9/16 and was an active client at the time of the licensing inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure staff are retrained on documentation of the treatment plan including timelines. Client #12 missing treatment plan was unable to be corrected due to client discharge on 8/12/2016 from suboxone OP. He was admitted to suboxone maintenance on 8/12/16 and a treatment plan was done on 10/3/16 by his new counselor Latisha Bemis.
Compliance will be achieved by 1/31/17
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records and a conversation with the facility staff, conducted from 11/29/16 thru 12/2/16, the facility failed to document the proposed type of support services in client records # 13, 15, 16, 20, 21, 23, & 24.
Client #13 had a comprehensive treatment plan documented on 3/10/16.
Client #15 had a comprehensive treatment plan documented on 4/19/16.
Client #16 had a comprehensive treatment plan documented on 1/12/16.
Client #20 had a comprehensive treatment plan documented on 5/19/16.
Client #21 had a comprehensive treatment plan documented on 5/19/16.
Client #23 had a comprehensive treatment plan documented on 4/14/16.
Client #24 had a comprehensive treatment plan documented on 4/11/16.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure staff is retrained on completion of treatment plans, specifically pertaining to support services documentation. This will be monitored through monthly chart reviews and staff supervisions. Compliance will be achieved by 1/31/17. |
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 client records and a conversation with the facility staff, conducted from 11/29/16 thru 12/2/16, the facility failed to document a treatment plan update every 60 days in client records # 8, 11, 13, 16, 17, 21 & 23.
Client #8 was admitted on 1/21/16 and was discharged 10/11/16. A treatment plan update was due by 10/4/16 but was not documented at the time of the licensing inspection.
Client #11 was admitted on 2/16/16 and was an active client at the time of the licensing inspection. A comprehensive treatment plan was documented on 6/8/16. A treatment plan update was due by 8/8/16 but was not documented until 9/1/16.
Client #13 was admitted on 2/12/16 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 5/12/16. Another treatment plan update was due by 7/12/16 but was not documented until 9/22/16.
Client #16 was admitted on 1/12/16 and was discharged 7/1/16. A comprehensive treatment plan was documented on 1/12/16. A treatment plan update was due by 3/12/16 but was not documented until 3/25/16. A subsequent update was due by 5/25/16 but was not documented until 6/16/16.
Client #17 was admitted on 6/9/16 and was discharged 9/16/16. A comprehensive treatment plan was documented on 6/23/16. A treatment plan update was due by 8/23/16 but was not documented at the time of the licensing inspection.
Client #21 was admitted on 5/19/16 and was discharged 8/11/16. A comprehensive treatment plan was documented on 5/19/16. A treatment plan update was due by 7/19/16 but was but was not documented until 8/4/16.
Client #23 was admitted on 3/22/16 and was discharged 10/5/16. A comprehensive treatment plan was documented on 4/14/16. A treatment plan update was due by 6/14/16 but was but was not documented until 6/28/16.
This information was discussed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure staff is retrained on treatment plan reviews and updates, specifically the timelines of 60 day updates. Compliance will be monitored through monthly chart reviews and staff supervision. Client charts 11,13,16,and 21 had treatment plan updates done late but were in the charts at inspection. Client
8, 17, and 23 are no longer in treatment so program unable to update. Compliance will be achieved by 1/31/17 |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records and a conversation with the facility staff, conducted from 11/29/16 thru 12/2/16, the facility failed to document a discharge summary in client records # 16, 23 & 24.
Client #16 was admitted on 1/12/16 and was discharged 7/1/16.
Client #23 was admitted on 3/22/16 and was discharged 10/5/16.
Client #24 was admitted on 4/4/16 and was discharged 6/1/16.
This information was discussed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure staff is retrained on proper completion of discharge summary within the 7 day time frame. Client charts 16, 23, and 24 discharge summaries were completed by the Clinical Supervisor. Discharge Summaries will be scanned into ECR prior to 1/31/17 Compliance will be reviewed by monthly chart reviews and staff supervisions. Compliance will be achieved by 1/31/17. |