INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 2-3, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. York Inpatient 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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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
During an on-site licensure inspection conducted October 2-3, 2019, the facility did not provide either individual paper towels or a mechanical dryer in each bathroom.
Eleven bathrooms were missing individual paper towels or a mechanical dryer in each bathroom.
This was reviewed with facility staff during the licensing process.
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Plan of Correction
Correction Completed. Paper towel dispensers were installed in each client bathroom. Installation was completed on 10/22/2019. Housekeeping is responsible for checking them daily and refilling them as necessary. Housekeeping supervisor will check with staff to ensure this is happening. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
During an on-site licensure inspection conducted October 2-3, 2019, the facility failed to instruct all staff in the use of the fire extinguished upon staff employment. Employee #1 was hired on August 20, 2019 and was current in that position. Employee #1 did not receive fire extinguisher training until October 3, 2019.
This was reviewed with facility staff during the licensing process.
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Plan of Correction
On the first day of employment all staff will be trained on fire extinguisher use. The supervisor is responsible for providing the training on the new hires their first day of employment. Staff will sign that they have been trained on a training form and kept in their employee files. |
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
During a licensing inspection conducted on October 2-3, 2019, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 2.
Client # 2 was admitted on September 4, 2019 and was still active at the time of the inspection. A voluntary and informed consent to disclose information form signed and dated September 12, 2019 to a government agency allowed for the release of: PPD results.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical/Medical Supervisors will review the guidelines of 255.5 and what can be shared and not shared under 255.5. For a period of one month, and Supervisors will do monthly audits on charts to ensure that staff are abiding by 255.5 in their documentation to collateral contacts. A checklist will be given to all staff at the first staff meeting on November 26,2019 outlining who consents need to be obtained for. In addition, sample releases that have been filled out properly will be given to staff to use as a sample for how to correctly complete releases of information in our electronic health record. The staff will be informed that they are to use the chart checklist with each new client entering services to ensure all the proper releases are obtained. This will be documented in the staff meeting minutes. Clinical/Medical Supervisors will perform random chart audits to ensure that releases are being filled out correctly and that they are all present and that if any changes or additions to collaterals have been made, that the appropriate release is present. During the Clinical Supervisor signing off on the Level of Care Assessment for their staff, they will also assure that the correct releases are present and filled out appropriately for the client. The results of the chart audits will be reviewed with staff during individual supervision and documented in individual supervision notes |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During an on-site licensure inspection conducted October 2-3, 2019, the project inform clients that the project may not discriminate in the provision of services on the basis of color in seven of seven client files reviewed.
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Plan of Correction
The policy and procedures manual was updated by the Policy and Procedure committee to include race, sex, color, religious creed, ethnicity, color, disability, ancestry, marital status, national origin (including limited English Proficiency), age, sexual orientation or gender identity preference. Chief Compliance Officer ensured completion of policy by November 01, 2019. The program director will be responsible to ensure that the new policy is shared with all staff by Nov 15, 2019. |