INITIAL COMMENTS
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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 was conducted on November 4, 2020 and client records review 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:
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Plan of Correction
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705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based on a physical plant inspection on November 4, 2020 the facility failed to ensure each resident had a storage area for clothing.
Room 126 was a double occupancy room and only had one dresser to store clothing.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Prior to admission to any room the BHT staff will inspect the physical space of the room to ensure that there sufficient number of beds and dressers in each room to accommodate the number of individuals that will be assigned to the room. This was rectified during the inspection on 11/4/2020. |
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
Based on a physical plant inspection on November 4, 2020 the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom.
Room 128 did not have either individual paper towels or a mechanical dryer in the bathroom.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
All client occupied bathrooms will have paper towels available to them and these paper towel products will be replenished on a daily basis by housekeeping staff members. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on November 4, 2020 the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag.
The fire extinguisher outside of room 127 was missing the extinguisher tag and inspection tag.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Plan of Correction:
Fire extinguishers within the facility are inspected on a monthly basis by facilities supervisor or designee. Yearly inspections are completed by the fire department in accordance with regulations. Facilities staff will keep a tracking sheet of monthly inspections and will ensure all tags are visible and up to date. Random spot checks of fire extinguishers will be completed by leadership staff on a weekly basis to ensure all extinguishers in the building have tags attached to the fire extinguisher. Fire extinguisher tag was replaced after facility inspection on 11/4/2020.
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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 one of eleven client records reviewed, the facility failed to provide documentation of an informed and voluntary consent from the client for the disclosure of information in client record # 2.
Client # 2 was admitted on February 18, 2021 and was still active at the time of the inspection. There was no documentation of an informed and voluntary consent from the client for the disclosure of information for a funding source in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon admission intake or nursing staff will complete all necessary consents for treatment including the consent to treat and will have the client sign the form. The intake/Case Coordinator supervisor or designee will review all client intake forms each day after admission has occurred to ensure that the forms are completed in full as required. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on observing medication pass at 11:45am on November 4, 2020 the facility failed to follow their medication administration policy. The policy indicates that client ' s self-administer medication. While observing the medication pass the employee removed three medications from the package labeled with the client ' s name on it and placed them into a cup and then gave it to the client to ingest.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All medical technician staff and nursing staff were re-educated on the self-administration policy on 11/5/2020 by Nursing Manager during shift changes. Nursing Manager and Office Manager will review during staff meetings with all shifts on a monthly basis as part of on-going supervisions and staff meetings. Nurse Manager/Charge Nurses or Designee will complete random medication pass observations on all shifts on a monthly basis to ensure that the self administration policy is being followed as written and to ensure compliance to the standards. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on two of two discharged client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 7 days of discharge.
Client # 3 was admitted on January 20, 2021 and was discharged on January 26, 2021. There was no documentation up follow-up information in the client record.
Client # 4 was admitted on February 8, 2021 and was discharged on February 12, 2021. There was no documentation up follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of March 2021 Case Coordinators are required to contact each individual who has been discharged within 7 days of discharge. Case coordinators are required to document the follow up phone call in a Memo to chart with the content of the phone call. Random Chart audits are conducted on a monthly basis by the Intake/Case Coordinator Supervisor to ensure compliance to the regulations. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on two of three of patient records reviewed, the facility failed to provide identification of the patient to verify the individual has reached 18 years of age.
Patient # 9 was admitted on February 1, 2021 and was still active at the time of the inspection. There was no identification documented in the client record.
Patient # 10 was admitted on January 29, 2021 and was still active at the time of the inspection. There was no identification documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon admission intake staff will obtain, copy and upload the client's ID into the medical record. If physical ID is unavailable Intake staff will obtain the verification of the individual through their insurance benefits and will complete the document within the record that demonstrates this verification as allowable by licensing alert 01-201 |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on two of three of patient records reviewed, the facility failed to provide identification of the patient to verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
Patient # 9 was admitted on February 1, 2021 and was still active at the time of the inspection. There was no identification documented in the client record.
Patient # 10 was admitted on January 29, 2021 and was still active at the time of the inspection. There was no identification documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon admission intake staff will obtain, copy and upload the client's ID into the medical record. If physical ID is unavailable Intake staff will obtain the verification of the individual through their insurance benefits and will complete the document within the record that demonstrates this verification as allowable by licensing alert 01-2018. |
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.
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Observations
Based on one of three patient records reviewed, the facility failed to 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 and prior to administration of an agent.
Patient # 10 was admitted on January 29, 2021 and was still active at the time of the inspection. The patient was inducted on an agent on February 10, 2021 and there was no documentation of a face to face determination in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After our internal review of this finding we found this documentation to be present in the electronic record. Office Manager, Nursing Manager and Executive Director will review charts for completion of face to face determination of SA history that meets criteria for administration of maintenance treatment each month to ensure that the documents are clearly completed as a face to face note and viewable within the chart to ensure that we meet regulations for DDAP and that the documents are viewable for anyone viewing chart for compliance.
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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.
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Observations
Based on one 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 in patient record # 10.
Patient # 10 was admitted on January 29, 2021 and was still active at the time of the inspection. There was no documentation of an informed, voluntary, written consent for treatment in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
After our internal review of this finding we found this documentation to be present in the electronic record. Office Manager, Nursing Manager and Executive Director will review charts for completion of written consent for purposes of maintenance or detoxication each month to ensure that the documents are completed and viewable within the chart to ensure that we meet regulations for DDAP and that the documents are viewable for anyone viewing chart for compliance.
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on one of one applicable patient record reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within seven days of discharge.
Patient # 11 was admitted on October 14, 2020 and discharged on November 10, 2020. There was no documentation of follow-up information in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of March 2021 Case Coordinators are required to contact each individual who has been discharged within 7 days of discharge. Case coordinators are required to document the follow up phone call in a Memo to chart with the content of the phone call. Random Chart audits are conducted on a monthly basis by the Intake/Case Coordinator Supervisor to ensure compliance to the regulations. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on two of four client records reviewed, the facility failed to provide a complete client record to include a physical examination in client records # 7 and 8.
Client #7 was admitted on February 27, 2020 and was discharged on April 1, 2020. There was no documentation of a physical examination in the client record.
Client #8 was admitted on September 14, 2020 and was discharged on October 4, 2020. There was no documentation of a physical examination in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After our internal review of this finding we found this documentation to be present in the electronic record. Office Manager, Nursing Manager and Executive Director will review charts for History and Physicals each week to ensure that the documents are completed and viewable within the chart to ensure that we meet regulations for DDAP and that the documents are viewable for anyone viewing chart for compliance.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on two of four client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records # 5 and 6.
Client # 5 was admitted on January 25, 2021 and was still active at the time of the inspection. A treatment plan developed with the client on January 26, 2021 and updated February 12, and February 25, 2021 indicating individual sessions weekly and group sessions five times weekly. After a review of progress notes and record of service there was no documentation of individual sessions the weeks of February 7-13, and 14-20.
Client # 6 was admitted on January 3, 2021 and was still active at the time of the inspection. A treatment plan developed with the client on January 11, 2021 and updated February 3, 2021 indicating individual sessions weekly and group sessions five times weekly. After a review of progress notes and record of service there was no documentation of individual sessions the weeks of January 24-30, and 31- February 13.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Directors will complete weekly chart audits to ensure compliance to regulations as it pertains to timely completion of all required documentation. Clinical Director will review charts each Monday morning and will review progress notes for each active client and will compare to what is written in the client's chart to ensure that the treatment sessions are occurring as prescribed in the client's treatment plan. Clinicians are required to have treatment progress notes completed within 24 hours of services being provided. Clinical Director will provide individual feedback to each clinician regarding their caseload and if there is any missing documentation clinician will be required to complete the necessary documentation with 24 hours of receiving feedback from the clinical director. |