INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Pyramid Healthcare Lehigh Valley, Inc was found to not 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
The facility failed to prepare alternate exit routes to be used during fire drills.
Fire drills completed between November 29, 2017 and June 14, 2018 did not indicate an exit route used for the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/1/18, the facilitation of fire drills, and documentation of said fire drills, will also include the exact location of where the fire occurred in the building, along with the specific exit route utilized by clients and staff. Regional Maintenance Director to facilitate change of documentation, effective 9/1/18, with on site maintenance staff. Responsibility for oversight of this process will be a coordination between Program Director and onsite maintenance personnel where upon Program Director and maintenance staff will review fire drill logs monthly to ensure compliance in this area. |
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 release forms for funding sources within the parameters of 255.5(b) in seven out of seven client records.
Client #1 was admitted on July 9, 2018 and was still active at the time of the survey. A release of records to SCA-Lehigh was signed by the client on July 9, 2018 for the five points outlined in 255.5(b) plus general progress updates, medication administration record, psychological assessment, medical history and physical, psychiatric evaluation and treatment progress updates.
Client #2 was admitted on May 14, 2018 and was still active at the time of the survey. A release for records to Magellan-Montgomery was signed by the client on May 14, 2018 for the five points outlined in 255.5(b) plus general progress updates, psychological assessment, psychiatric evaluation, medication administration record, medical history and physical and treatment progress updates.
Client #3 was admitted on June 5, 2018 and was still active at the time of the survey. Releases for records to Magellan-Lehigh and SCA-Lehigh were signed by the client on June 5, 2018 for the five points outlined in 255.5(b) plus general progress updates, psychological assessment, psychiatric evaluation, medication administration record, medical history and physical and treatment progress updates.
Client # 4 was admitted on December 5, 2017 and was discharged on January 31, 2018.
Releases for records to Magellan and Montgomery County DPW were signed by the client on December 5, 2017 for the five points outlined in 255.5(b) plus general progress updates.
Client #5 was admitted on November 28, 2017 and was discharged on February 12, 2018. Releases for records to Magellan and Delaware County DPW were signed by the client on November 28, 2017 for the five points outlined in 255.5(b) plus general progress updates.
Client #6 was admitted on February 14, 2018 and was discharged on May 15, 2018. Releases for records to Magellan and Bucks County DPW were signed on February 14, 2018 for the five points outlined in 255.5(b) plus general progress updates, medication administration record, psychological evaluation, psychiatric evaluation, medical history and physical and treatment progress updates.
Client #7 was admitted on May 3, 2018 and was discharged on July 16, 2018. Releases for records to Magellan and Bucks County DPW were signed on May 3, 2018 for the five points outlined in 255.5(b) plus general progress updates, psychological assessments, psychiatric evaluation, medication administration record, medical history and physical and treatment progress updates.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/7/2018, all consents specific to funders/payer sources will reflect the release of only information outlined under regulatory guidelines #255.5. Effective 9/1/2018, Clinical Supervisor will facilitate a training with all intake staff specific to the completion of said consent forms. Clinical Supervisor will monitor the consents by monthly chart audits to ensure compliance with this regulation. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The facility failed to update treatment plans within thirty days in three out of seven client records.
Client # 2 was admitted on May 14, 2018 and was still active at the time of the inspection. A treatment plan update was completed on June 28, 2018 and the next was scheduled to be completed no later than July 28, 2018, however was not in the record on the date of inspection.
Client # 3 was admitted on June 5, 2018 and was still active at the time of the inspection. A treatment plan was completed on June 21, 2018 with the next scheduled treatment plan to be completed no later than July 21, 2018. It was completed and signed by the client and counselor on August 1, 2018.
Client #4 was admitted on December 4, 2017 and was discharged on January 31, 2018. A comprehensive treatment plan was completed on December 5, 2017 with the next to be completed no later than January 5, 2018. It was completed and signed by the client and counselor on January 17, 2018.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
Effective 9/1/2018, Clinical Supervisor to facilitate a refresher training, for all clinical staff, on the required timeframes, for both short term (14 days) and long term (30 days) LOC, for treatment planning guidelines. Clinical Supervisor to monitor charts through monthly chart audits to ensure compliance to established treatment plan update time frames. Clinical Supervisor to provide audit outcomes, to Program Director, at monthly leadership meetings. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
The facility failed to complete follow up in two out of four discharged client records.
Client # 5 was admitted on November 28, 2017 and discharged on February 12, 2018. There was no followup documented in this client's chart as of the date of inspection.
Client # 6 was admitted on February 14, 2018 and discharged on May 15, 2018. There was no followup documented in this client's chart as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/1/2018, Clinical Supervisor and Program Director to meet to identify staff responsible for follow up calls for client discharge. On 9/8/2018, Clinical Supervisor and Program Director to meet with selected staff to develop an organized process for tracking discharged clients and documenting follow up phone calls. All follow up phone calls to be documented in electronic chart record. Identified staff to report, in monthly leadership meeting, to Program Director, outcome of phone calls for previous month. Program Director to have oversight of established process. |