INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5-7, 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 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
During a licensing inspection conducted on August 5-7, 2019, the facility failed to ensure that employee's # 10, #11, #12 and #13 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee # 10 was hired as a direct support professional on October 15, 2016 and was due to have the communicable disease trainings no later than October 15, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee # 11 was hired as a direct support professional on August 15, 2015 and was due to have the communicable disease trainings no later than August 15, 2017. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee # 12 was hired as a direct support professional on August 2, 2015 and was due to have the communicable disease trainings no later than August 2, 2017. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee # 13 was hired as a direct support professional on March 6, 2017 and was due to have the communicable disease trainings no later than March 6, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and BHT manager for the facility will track/monitor completion of staff Communicable Diseases training for all employees. Executive Director will ensure that all Department Managers monitor their assigned staff for compliance of Communicable Diseases training attendance through supervision. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. Target date for completion is 10/31/2019 |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
During a licensing inspection conducted on August 5-7, 2019, the facility failed to ensure counseling sessions could not be heard outside the counseling room. Group sessions being conducted could be heard in a group room on the other side of the attached wall. Also, patients and staff could be heard in the nurse's station in the same group room from the other side.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director will purchase additional white noise/sound machines and ensure that all rooms that counseling is provided in has sound machines present. Additionally all nursing areas will also have sound machines installed to ensure confidentiality.
Maintenance will conduct monthly checks and document on a log to ensure batteries in the machines are in working order and being used daily.
Executive director will monitor the logs.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
During a licensing inspection conducted on August 5-7, 2019, the facility failed to ensure hot water temperatures did not exceed 120 degrees Fahrenheit.
Two bathrooms on the seconds floor of the "Main" house had water temperatures exceeding 120 degrees Fahrenheit. The first bathroom had a temperature read of 128 degrees Fahrenheit and the second bathroom had a temperature reading of 130 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 08/9/19, all the water temperatures were adjusted to 110 degree Fahrenheit and were tested by the maintenance department. The temperatures were review by the director and documented.
As of 08/12/19, the water temperatures are being tested monthly and documented on a temperature log by the maintenance department.
Log will be reviewed monthly by executive director to ensure compliance.
Target date for completion is 10/31/19 |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
During a licensing inspection conducted on August 5-7, 2019, the facility failed to provide documentation of fire drills being conducted monthly during the months of July 2018 through July 2019 and to include each of the buildings on the campus.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/12/19, The policy for fire drill was reviewed with Leadership staff, Risk Management Committee, and Administrative Coordinator.
As of 8/12/19, fire drills are to be performed for all buildings on a monthly basis with two per year being performed for each building on the overnight shift.
All the fire drill will be documented in a log by the risk manager , director of maintenance, and BHT supervisors on shift.
Executive Director will review the fire drills in monthly risk meetings on a monthly basis. Target date for completion is 10/31/19 |
709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
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Observations
During a Project Wide review of Policy and Procedures, the facilities Client Rights policy was missing - sex and marital status in 709.30 (2), and Reasons for removing sections shall be documented in the record in 709.30 (3).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual will be updated by the Policy and procedure committee to include sex and marital status in section 709.30. Chief Compliance Officer will ensure completion of policy by Sept 1, 2019. The program director will be responsible to ensure that the new policy is shared with all staff by Sept 15, 2019. |
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 August 5-7, 2019, the facility failed to keep disclosures of patient identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 3 and 5.
Client # 3 was admitted on June 23, 2019 and was still an active client at the time of the inspection. An informed and voluntary consent to disclose information signed and dated on July 11, 2019 to a funding source allowed for the release of a Medication Administration record, psychological assessment, psychological evaluation, and history and physical.
Client # 5 was admitted on January 25, 2019 and discharged on April 1, 2019. An informed and voluntary consent to disclose information signed and dated on January 22, 2019 allowed for the disclosure of presence in treatment, prognosis, nature/type of program, progress in treatment, and whether or not relapse occurred without naming the person, agency, or organization to whom the discloser is to be made to.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will provide training to intake and all clinical staff on appropriate release of information depending on the entity to which the information is being released to.
This will be reviewed and documented during weekly supervision with clinical and intake staff.
Executive Director will monitor compliance in this area through weekly documented supervision and completion of monthly open and closed chart audits.
All current client records will be reviewed by clinical supervisor and amended with the correct release of information and signed by the client. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
During a licensing inspection conducted August 5-7, 2019, the facility failed to provide documentation that the client was notified of their rights in twelve of twelve client records reviewed. Clients are provided a handbook to include client rights. The handbook does not contain:
709.30 (2) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Plan of Correction
The handbook and client rights were updated on 8/20/19 by the executive director to reflect the language:
"The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record."
The new handbook/client rights was distributed on 8/20/19 to all staff and clinical director will monitor and ensure that the updated copy is being utilized and will destroy all remaining old copies. |
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
During a licensing inspection conducted on August 5-7, 2019, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in one applicable record reviewed.
Client # 12 was admitted on May 16, 2018 and was administratively discharged on July 5, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review with clinical staff the need to notify a client in writing of the decision to involuntarily terminate the client from treatment at the facility, which shows the right to appeal the decision. The written notice will include the reasons for the termination.
Clinical Supervisor will monitor compliance in this area through monthly documented supervision and completion of monthly open and closed chart audits.
Target date for completion is 10/31/2019 |
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
During a licensing inspection conducted on August 5-7, 2019, the facility failed to provide documentation verifying an emergency contact for patient # 3.
Patient # 3 was admitted on June 23, 2019 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will review with Intake staff and train in the need to have an emergency contact in the client's chart during intake staff's weekly documented supervision.
Should a client chose not to identify a emergency contact, the intake staff will document this in a memo to chart within the clients file. Executive Director will provide this training to intake staff and monitor compliance in this area through weekly documented supervision and completion of monthly open and closed chart audits. |
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
During a licensing inspection conducted on August 5-7, 2019, the facility failed to provide documentation of informed patient consent for use of buprenorphine in patient record # 1.
Patient # 1 was admitted on June 5, 2019 and was still active at the time of the inspection. The patient received a renewal prescription while in treatment without a consent form signed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nurse manager will train all nursing staff on completing a nursing assessment and obtaining consent to treat with Buprenorphine for all clients entering our facility as a transfer from another Buprenorphine provider as well as all new admissions into our Buprenorphine maintenance program.
Nurse manager will ensure compliance with this by conducting monthly chart audits on all medicated assisted treatment clients in our care for open and closed charts. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
During a licensing inspection conducted on August 5-7, 2019, the facility failed to provide documentation of a psychosocial evaluation being completed in patient record # 2.
Patient # 2 was admitted on July 12, 2019 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure that psychosocial evaluations are completed for all clients within 3 days of admission to the program and will provide documentation training to all clinical staff.
Monthly chart audits will be conducted by the clinical director to ensure psychosocial evaluations are being completed in compliance with the regulation as well being monitored in group and individual supervision. |
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
During a licensing inspection conducted on August 5-7, 2019, the project failed to provide documentation ensuring counseling services are provided according to the individual treatment and rehabilitation plan in 4 of 12 records reviewed.
Patient #1 was admitted on June 5, 2019 and was still an active patient at the time of the inspection. The comprehensive treatment plan dated June 10, 2019 indicated one individual session weekly and five group sessions weekly. An individual treatment and rehabilitation plan update dated July 26, 2019 indicated individual sessions bi-weekly. The chart's record of service and progress notes indicated that the client had not received individual sessions the weeks of June 16-22, 23-29, July 14-20, 21-26.
Patient # 2 was admitted on July 12, 2019 and was still an active patient at the time of the inspection. The comprehensive treatment plan dated July 15, 2019 indicated one individual session weekly and five group sessions weekly. The chart's record of service and progress notes indicated that the patient had not received individual sessions the weeks of July 14-20, 21-27, July 28-August 3.
Patient # 3 was admitted on June 23, 2019 and was still an active patient at the time of the inspection. The comprehensive treatment plan dated June 24, 2019 indicated one individual session weekly and five group sessions weekly. The chart's record of service and progress notes indicated that the patient had not received individual sessions the weeks of July 7-13, 21-27, July 28-August 3.
Patient # 8 was admitted on July 9, 2019 and was still an active patient at the time of the inspection. The comprehensive treatment plan dated July 11, 2019 indicated one individual session weekly and five group sessions weekly. The chart's record of service and progress notes indicated that the patient had not received individual sessions the week of July 21-27.
Patient # 9 was admitted on July 17, 2019 and was still an active patient at the time of the inspection. The comprehensive treatment plan dated July 19, 2019 indicated one individual session weekly and five group sessions weekly. The chart's record of service and progress notes indicated that the patient had not received any individual sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director will provide training to the clinical team on treatment plan development and ensuring that the treatment plan being developed and implemented matches the services provided.
This will also be reviewed and monitored though monthly individual supervision and weekly group supervision by the clinical director and clinicians.
Additionally, this will be reviewed and monitored through monthly compliance audits by the regional clinical coordinator. |