INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, a physical plant inspection was conducted on October 14, 2020 and client record review was conducted on March 1-16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Pyramid Healthcare Inc. 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:
|
Plan of Correction
|
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
|
Observations
Based on an onsite inspection the facility failed to maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
A windowpane was broken on the second-floor stair landing facing the outside fire escape.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The windowpane has been fixed since onsite inspection. Maintenance will complete a weekly walkthrough of the facility every Friday afternoon to ensure all windows and building structures are intact. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
|
Observations
Based on one of three patient records reviewed, the facility failed to document current physiological dependence upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
Patient # 3 was admitted on March 4, 2021 and was still active at the time of the inspection. The patient was prescribed an agent on March 8, 2021 without documentation in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Medical staff will cross reference the level of care assessment, nursing assessment, and the history and physical to ensure one year dependency prior to admission. A urine drug screen will be completed upon admission to ensure opioid dependency prior to the start of maintenance treatment. Medical director and director of nursing to have oversight to establish plan and plan is being followed. Target date for this plan is May 1, 2021. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on three of three patient records reviewed, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment.
Patient # 1 was admitted on February 4, 2021 and was discharged March 8, 2021. There was not an informed, voluntary, written consent prior to the administration of an agent in the patient record.
Patient # 2 was admitted on January 26, 2021 and was discharged February 25, 2021. There was not an informed, voluntary, written consent prior to the administration of an agent in the patient record.
Patient # 3 was admitted on March 4, 2021 and was still active at the time of the inspection. There was not an informed, voluntary, written consent prior to the administration of an agent in the patient record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Prior to the start of MAT, CRNP will complete an informed consent for the administration of an agent in the patient record. Medical director and director of nursing to have oversight to ensure completion of MAT consent is occurring. Target date is April 9, 2021. |