INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. Pine Ridge 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 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
The facility failed to ventilate toilets and wash rooms with an exhaust fan or window.A physical plant inspection was conducted on November 15, 2016. One of the bathrooms on the upper floor of the "B House" was found to have no window and no fan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance evaluated bathroom in B House Room 6. An exhaust fan was installed in the bathroom on 11/17/2016. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to maintain at least two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.A physical plant inspection was conducted on November 15, 2016. At the time of the inspection, two of the residential buildings, Building D and Building E, were observed to have a basement with only one exit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance evaluated the presenting area. A locked door will be installed at the landing,closing off the basement area. This will allow a 2nd form of egress with the outside door, on the main floor. |
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
The facility failed to obtain informed and voluntary consent forms for the disclosure of information contained in the client record in ten of ten client records reviewed on November 15, 2016.Ten client records were reviewed. Ten records required an informed and voluntary consent to release client information. The facility failed to obtain an informed and voluntary consent to release information in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.The consent to release information form states that revocation must be in writing. 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.In addition, consents to release information to criminal justice authorities were observed to include a statement that the consent could not be revoked. There were no court orders mandating treatment documented for these clients and therefore, the consents could be revoked verbally or in writing at any time.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 post test completion and monitored by Human Resource Coordinators. Program Director and Lead Clinician will conduct monthly chart audits, ensuring these clinical areas are documented correctly and consent contain appropriate information. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
The facility failed to document that a copy of signed consents were offered to the client in ten of ten client records.Ten client records were reviewed on November 15, 2016. All ten client records included at least one signed consent in which the client was not offered a copy.These findings were reviewed 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. 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 post test completion and monitored by Human Resource Coordinators. Program Director and Lead Clinician will conduct monthly chart audits, ensuring these clinical areas are corrected. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of two client records.Ten client records were reviewed on November 15, 2016. Two of clients reviewed were involuntarily terminated from treatment at the project. Client records # 9 and 10 did not include documentation of a written notification of termination.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a client is involuntarily terminated, the counselor will discuss the involuntary termination document with the individual. The Counselor will document in the notes section of the clients chart, that a copy of the involuntary notification of termination was offered and provided to the client. Lead Counselor and Program Director will ensure that this is occurring with each discharge. This will be added to our monthly discharge chart audit, which is conducted by the Lead Counselor and Program Director. |