INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 10-11, 2024 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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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of physician time sheets and census record, the facility failed to provide the required number of hours onsite for the physician based on the census. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.During the week of February 18, 2024, the patient census was 444. The facility was required to provide at least 10.26 physician hours. There were 9.5 hours documented. During the week of February 25, 2024, the patient census was 441. The facility was required to provide at least 10.19 physician hours. There were 7.75 hours documented.During the week of March 3, 2024, the patient census was 443. The facility was required to provide at least 10.23 physician hours. There were 4.5 documented.During the week of March 10, 2024, the patient census was 442. The facility was required to provide at least 10.2 physician hours. There were 3.75 documented.During the week of March 17, 2024, the patient census was 442. The facility was required to provide at least 10.2 physician hours. There were 5 documented. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will review schedule with medical director prior to the start of each week to ensure that the physician is scheduled to provide one-third of all required physician time. Executive director will also track to ensure that the remaining time provided by a certified registered nurse practitioner or physician assistant will not exceed two-thirds of the required narcotic treatment physician time. This will ensure that the required narcotic treatment physician time is scheduled for each week.
Executive director will utilize a tracker to maintain a weekly record of physician hours scheduled for each week that calculates physician hours needed in relation to weekly census totals. This tracker will calculate the narcotic treatment physician time required for each week and ensure that the medical director provides at least one-third of all required hours. Executive director will also maintain a weekly census report to ensure that the medical is scheduled for at least one-third of all required narcotic treatment physician time as it pertains to weekly census numbers. This was implemented starting July 19, 2024.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the facility failed to maintain onsite a photograph of each patient which includes that patient's name and birth date. The narcotic treatment program shall update the photograph every 3 years in one out of ten applicable records reviewed.Patient #2 was admitted on September 9, 2020 and was still active at the time of the inspection. The picture in the patient's record was dated October 20, 2020.This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Executive director, clinical supervisor, and lead counselor will review all clients who have been in treatment for 2 years to ensure that client pictures are updated prior to clients being in treatment 3 years. Methasoft flags will be placed on all clients who are in need of updated pictures. This was implemented on 7/23/2024.
Executive director, clinical supervisor, and lead counselor will review all clients who have been in treatment for 3 years or more to ensure that client pictures are updated in system. Methasoft flags will be placed on all clients who are in need of updated pictures. This was implemented on 7/23/2024.
Administrative assistant will maintain pictures for all clients who have flags in the Methasoft system to obtain updated pictures. Administrative assistant will support with uploading new client pictures in ECR. Executive director and clinical supervisor will provide support as needed to help ensure that updated client pictures are uploaded in the electronic clinical record and in the Methasoft program that is utilized for dosing clients by 8/20/2024.
Completion Date: 8/20/2024
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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 patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in one out of four applicable records reviewed.Patient #10 was admitted on October 20, 2023 and was still active at the time of the inspection. In June 2024, the patient received only 1 hour of psychotherapy. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All counselors will be required to keep a case tracker of clients on their caseload that specifically tracks treatment attendance in relation to client attending an average of 2.5 hours of psychotherapy per month during the patient's first 2 years and 1 hour of which shall be individual psychotherapy. The case tracker will be updated on a weekly basis. Case trackers will be reviewed for monthly group attendance and tracking monthly psychotherapy hours in staff meeting on 7/25/2024.
Clinical supervisor and lead counselor will audit 15% of client charts prior to monthly supervision with counselors. Leadership team will review that treatment services are scheduled and occurring based on 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy. This audit will be done by reviewing psychotherapy hours for each month the client is in treatment. Leadership staff will check case trackers every two weeks for group attendance. Leadership staff will check case trackers every 2 weeks to ensure that 2.5 hours of psychotherapy per month are occurring during the patient's first two years of treatment, and one hour of which is individual psychotherapy. This was implemented on 7/23/2024.
Pyramid Healthcare's regional quality team will be auditing to ensure that 2.5 hours of psychotherapy per month are occurring during the patient's first two years of treatment, and one hour of which is individual psychotherapy. Regional quality team will then meet with leadership team monthly to review their findings.
Completion Date: 7/25/2024
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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 patient records, the facility failed to document an annual physical examination within the regulatory timeframe in four out of five applicable records.Patient #5 was admitted on February 10, 2020 and was discharged on April 2, 2024. The annual physical examination was due no later than February 10, 2024; however, it was completed on February 27, 2024. Patient #7 was admitted on November 25, 2019 and was still active at the time of the inspection. The annual physical examination was due no later than November 25, 2023; however, it was completed on December 6, 2023. Patient #8 was admitted on January 18, 2017 and was still active at the time of the inspection. The annual physical examination was due no later than January 18, 2024; however, it was completed on January 24, 2024. Patient #9 was admitted on August 8, 2022 and was still active at the time of the inspection. The annual physical examination was due no later than August 8, 2023; however, it was completed on August 15, 2023. These findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Nursing staff will run annual reports in Methasoft system at least 60 days prior to client's annual due date to ensure that annual examination is scheduled and completed by within the regulatory time frame. Nursing staff will track upcoming annuals due and this list will be reviewed with executive director every 2 weeks. This was implemented and procedures were reviewed with nursing staff on 7/23/2024.
Executive director will review annual tracker with nursing staff, medical director, and certified registered nurse practitioner to ensure that annual evaluations are being scheduled and completed within the regulatory timeframe. This was be implemented and reviewed with medical team on 7/23/2024
Executive director will meet every 3 weeks with medical director to monitor that annual evaluation by the narcotic treatment physician is completed within the regulatory timeframe. The first meeting will occur on 7/23/2024 and continue every 3 weeks to help ensure compliance in relation to annual evaluations being scheduled and completed in the regulatory timeframe.
Completion Date: 8/1/2024
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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 patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe and ensure that the evaluation was signed by the medical director in three out of five applicable records. Patient #2 was admitted on September 9, 2020 and was still active at the time of the inspection. The annual clinical evaluation was due on September 9, 2023; however, it was completed on September 25, 2023.Patient #5 was admitted on February 20, 2020 and was discharged on April 2, 2024. The annual clinical evaluation was completed on February 6, 2024; however, it was not signed by the medical director.Patient #8 was admitted on January 18, 2017 and was still active at the time of the inspection. The annual clinical evaluation was due on January 18, 2024; however, it was completed on January 24, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All counselors will be required to keep a case tracker of clients on their caseload that specifically tracks the intake date for each client to monitor when annual evaluations need completed. All counselors will track to ensure that annual evaluations are completed prior to the client's anniversary of their intake date. The case tracker will be updated on a weekly basis by each counselor. Case trackers will be reviewed by clinical supervisor and/or lead counselor on a monthly basis to ensure that case trackers are being utilized. This will be implemented and reviewed with clinical team during treatment team staff meeting on 7/25/2024.
Clinical supervisor and lead counselor will audit 15% of client charts prior to monthly supervision with counselors. In conducting this audit leadership staff will specifically be looking to see that annual evaluations are being completed prior to client's anniversary of intake date and that medical director has signed off on the annual review. These audits will begin on 7/26/2024.
Executive director and/or clinical supervisor will meet with medical director to discuss the importance of reviewing and signing annual evaluations within 5 days of a counselor completing an annual evaluation. Executive director will also monitor medical director alerts in the electronic clinical record to ensure that annuals are signed within 5 days of a counselor completing an annual evaluation. This will begin on 7/25/2024.
Pyramid Healthcare's regional quality team will be auditing to see that counselor's complete annual evaluations prior to the client's anniversary of intake date. Pyramid Healthcare's regional quality team will also be auditing to see that medical director has signed off on the annual review within 5 days of a counselor completing the annual evaluation. Regional quality team will then meet with leadership team monthly to review their findings.
Completion Date: 7/26/2024
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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 patient records, the facility failed to document a treatment plan updates within guidelines established by the facility's policy and procedures manual in four out of eight applicable records reviewed. The facility's policy and procedures manual states the treatment plan updated must be every 60 days following for the first two years than 120 days thereafter.Patient #2 was admitted on September 9, 2020 and was still active at the time of the inspection. A treatment plan update was completed on October 9, 2023 and the next one was due no later than February 9, 2024; however, it was not completed until March 4, 2024. Patient #5 was admitted on February 10, 2020 and discharged on April 4, 2024. A treatment plan update was completed on July 27, 2023 and the next update was due no later than November 27, 2023; however, it was not completed until December 19, 2023.Patient #7 was admitted on November 25, 2019 and was still active at the time of the inspection. A treatment plan update was completed on August 23, 2023 and the next update was due no later than December 23. 2023; however, it was not completed until December 26, 2023. Patient #9 was admitted on August 8, 2022 and was still active at the time of the inspection. A treatment plan update was completed on December 14, 2023 and the next update was due no later than February 14, 2024; however, it was not completed until February 15, 2024.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the June 20, 2023 licensing inspection.
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Plan of Correction
All counselors will be required to keep a case tracker of their clients that specifically track treatment plan dates of completion and next due date. This will be updated on a daily basis. Case management trackers will be reviewed for treatment plan tracking during the treatment team staff meeting on 7/25/2024.
Clinical supervisor and/or lead counselor will review individualized case management trackers with counselors at the time of monthly individual supervision. This will allow us to ensure that treatment plans are reviewed and updated within the appropriate clinical intervals (60 days or 120 days as applicable).
Clinical supervisor will utilize counselor alerts (within the EMR system) to remind counselors at least 15 days ahead of time for treatment plans that need to reviewed and completed. Clinical supervisor will check counselor alerts each week to ensure that counselors are notified at least 15 days prior to treatment plan due dates to ensure that treatment plan is completed within the appropriate intervals. All counselors will schedule clients for monthly individual psychotherapy to help ensure that treatment plans are completed within the appropriate intervals. Clinical supervisor will begin to notify all counselors of upcoming treatment plan due dates on 7/26/2024.
Pyramid Healthcare's regional quality team will be auditing for treatment plan compliance. Regional quality team will then meet with leadership team monthly to review their findings.
Completion Date: 7/26/2024
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of patient records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in three out of eight applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed annually for patients in treatment longer than a year.Patient #2 was admitted on September 9, 2020 and was still active at the time of the inspection. No case consultation was completed in the previous year. Patient #7 was admitted on admitted on November 25, 2019 and was still active at the time of the inspection. No case consultation was completed in the previous year. Patient #8 was admitted on January 18, 2017 and was still active at the time of the inspection. No case consultation was completed in the previous year.These findings were reviewed with the facility staff during the licensing inspection process.
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Plan of Correction
All counselors will be required to keep a case tracker of their clients that specifically track case consultation notes in relation to 3 month, 6 month, and 9 month case consults. All counselors will also track to ensure that case consultations are completed annually for patients in treatment longer than a year. This case tracker will be updated on a daily basis. Case management trackers will be reviewed for case consultation tracking at the treatment staff meeting on 7/25/2024.
Clinical supervisor and/or lead counselor will review individualized case management trackers with counselors at the time of monthly individual supervision. This will ensure that case consults are being completed within the appropriate intervals. This was implemented starting on 7/19/2024.
Pyramid Healthcare's regional quality team will be auditing for compliance in relation to case consults being completed within the appropriate timeframes as indicated by the policy and procedures manual utilized at the facility. Regional quality team will then meet with leadership team monthly to review their findings.
Completion Date: 7/25/2024
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