INITIAL COMMENTS
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This report is a result of an on-site inspection related to the annual licensing, buprenorphine monitoring inspection and capacity increase request conducted on September 4 - 5, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the 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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705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on observation during a physical plant inspection, the facility failed to maintain a well-secured handrail for the steps leading to the front door of the aftercare program building.
The findings include:
A physical plant inspection was conducted with the facility director and maintenance staff on September 5, 2014 at approximately 9:15 AM. The facility has a new building that contains the aftercare program for residential clients. The new building has four steps leading to the front door. These steps did not have a handrail. The facility failed to maintain a well-secured handrail for the steps leading to the front door of the aftercare program building.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance crew erected a handrail for the steps leading to the front door of the aftercare program building on September 5, 2014 shortly after realizing one was required. The inspector took a picture of the erected handrail. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's fire drill records, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings include:
The facility's fire drill records were reviewed for the time frame of July 2013 through August 2014. The facility's sleeping hours are from 10:30 PM until 6:30 AM. The facility conducted a fire drill during sleeping hours on July 9, 2013 at 5:40 AM. The next fire drill during sleeping hours was due to be completed no later than January 2014. The facility did not conduct another fire drill during sleeping hours until March 28, 2014 at 5:10 AM. The facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The maintenance supervisor will provide a copy of the completed sleeping hours fire drill to the facility director at least once every six months. The maintenance director will ensure that the lead worker specifically documents in the fire drill log that a smoke detector or fire alarm had been set-off during sleep hours by reviewing the completed logs on a monthly basis. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis which included individual counseling, at least twice weekly, in three of the four client records.
The findings include:
Twenty five client records were reviewed on September 4-5, 2014. Four of the twenty five client records were reviewed for the partial hospitalization activity and required documentation of individual counseling at least twice weekly. Client records # 23, 24 and 25 did not include documentation of individual counseling at least twice weekly.
Client # 23 was admitted on August 6, 2014 and discharged on September 3, 2014. There was one individual counseling session documented for the week of August 17, 2014. There were no individual counseling sessions documented for the week of August 24, 2014.
Client # 24 was admitted on June 5, 2014 and discharged on July 8, 2014. There was one individual counseling session documented for the week of June 22, 2014.
Client # 25 was admitted on July 25, 2014 and discharged on August 12, 2014. There was one individual counseling session documented for the week of July 27, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will meet with the counselor of Clients #23, #24, and #25 regarding required frequency of individual counseling. The discussions will specifically focus on the importance of meeting with the clients no less than twice per week for individual counseling. The Clinical Supervisor and the Manager of Clinical Services will monitor ongoing compliance with the standard via monthly supervision and monitoring of client charts. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on review of patient records, the facility failed to complete an initial drug-screening urinalysis prior to the administration of Subutex, a narcotic agent, in three of ten patient records.
The findings include:
Twenty-five client records were reviewed on September 4 - 5, 2014. Ten records pertained to patients that were prescribed Subutex. The facility was required to complete an initial drug-screening urinalysis for these patients prior to the administration of Subutex, a narcotic agent. The facility failed to document an initial drug-screening urinalysis prior to the administration of Subutex in patient records # 2, 4 and 5.
Patient # 2 was admitted into treatment on July 14, 2014. The initial dose of Subutex was administered to patient # 2 on July 15, 2014 at 10:30 A.M. The urine screen results were not received by the facility until July 16, 2014. The facility failed to complete an initial drug-screening urinalysis prior to the administration of Subutex to patient # 2.
Patient # 4 was admitted into treatment on April 21, 2014. The initial dose of Subutex was administered to patient # 4 on April 22, 2014 at 8 A.M. The urine screen results were not received by the facility until April 23, 2014. The facility failed to complete an initial drug-screening urinalysis prior to the administration of Subutex to patient # 4.
Patient # 5 was admitted into treatment on June 29, 2014. The initial dose of Subutex was administered to patient # 5 on June 30, 2014 at 7:30 A.M. The urine screen results were not received by the facility until July 1, 2014. The facility failed to complete an initial drug-screening urinalysis prior to the administration of Subutex to patient # 5.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the inspection conducted on October 7 - 9, 2013.
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Plan of Correction
Drug Screen urinalysis will be completed prior to the administration of Subutex either through Quest results or on site urine dip. When a urine dip is completed, a copy will be placed in the client record. The Nurse Manager will reinforce this regulation at the next nursing meeting and will ensure completion through monthly chart monitoring. |