INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 19, 2010 licensure renewal inspection. The follow-up inspection was conducted on May 12, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Pyramid Healthcare Inc. - Transitions 2 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
Based on a review of personnel records, a review of the facility summary report, and a conversation with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training for eight of ten personnel/training records.
The findings include:
Sixteen personnel records were reviewed on October 1 and 4, 2010. The facility summary report was reviewed on October 18-19, 2010. Ten personnel were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for personnel records # 8, 9, 10, 11, 12, 13, 14 and 15.
Employee # 8 is a support staff and was hired August 11, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by August 11, 2009. The facility failed to provide documentation of TB/STD training.
Employee # 9 is a support staff and was hired April 11, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by April 11, 2010. The facility failed to provide documentation of TB/STD training.
Employee #10 is a support staff and was hired January 4, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by January 4, 2010. The facility failed to provide documentation of TB/STD training.
Employee #11 is a support staff and was hired August 25, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by August 25, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
Employee #12 is a support staff and was hired August 10, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by August 10, 2010. The facility failed to provide documentation of TB/STD training.
Employee #13 is a support staff and was hired July 18, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by July 18, 2009. The facility failed to provide documentation of TB/STD training.
Employee #14 is a support staff and was hired October 24, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by October 24, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
Employee #15 is a support staff and was hired February 22, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by February 22, 2010. The facility failed to provide documentation of TB/STD training.
** NOTE - As of May 12, 2011, the date of the plan of correction follow-up, this is still in non-compliance. There have been no changes.
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Plan of Correction
Staff in need of mandatory trainings have been identified by the HR department. The identified staff will be attending TB/STD Training on 5/26/2011 and HIV/AIDS Training on 7/14/2011. Program Director will follow-up in 90 days to ensure trainings were attended and cetifications of participation were placed in the employee's personnel files. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in ten of fourteen client records.
The findings include:
Fourteen client records were reviewed on May 12, 2011. Fourteen client records were required to include an informed and voluntary consent from the client prior to the disclosure of information.
Client record #1 - The client was admitted on 5-2-11. There is a release of information signed on 5-2-11, that does not include the name of the person, agency, or organization to whom disclosure is made.
Client record #2 - The client was admitted on 3-3-11. There is a release of information for an emergency contact, signed on 3-3-11, that does not include the specific information to be disclosed.
Client record #3 - The client was admitted on 4-22-11. There is a release of information signed on 4-22-11, that does not include the name of the person, agency, or organization to whom disclosure is made.
Client record #4 - The client was admitted on 4-19-11. There is a release of information signed on 4-19-11, that does not include the name of the person, agency, or organization to whom disclosure is made.
Client record #5 - The client was admitted on 4-9-11.
(1) There are two consent to release information forms signed by the client. The two consent to release information forms were blank relative to the name of the person, agency, or organization to whom disclosure is made, the specific information disclosed, the purpose of disclosure, the dated signature of the witness, and the expiration date of the consent. The client did sign both of the release forms, but the signature is not dated by the client.
(2) Seven out of the eight consent to release information forms in this client record did not include the dated signature of the witness.
(3) There is a consent to release information form for a crisis center that does not include the purpose of disclosure.
Client record #8 - The client was admitted on 2-8-11, and discharged on 3-28-11. The release of information to the drug court was signed on 2-21-11, but failed to include the specific information to be disclosed, the purpose of disclosure, and the dated signature of witness.
Client record #9 - The client was admitted on 3-4-11, and discharged on 4-20-11. The release of information for the client's son was signed on 3-4-11, but failed to include the dated signature of the witness.
Client record #10 - The client was admitted on 2-1-11. The release of information form for an emergency contact did not include the specific information to be disclosed. The specific information section on the release of information form was blank. This form was signed by the client on 2-1-11.
Client record #12 - The client was admitted on 3-7-11. The release of information to the mother did not include the specific information to be disclosed. The specific information section on the release of information form was blank. This was signed by client on 3-7-11.
Client record #14 - The client was admitted on 2-4-11. The release of information form to the father did not include the specific information to be disclosed. The specific information section on the release of information form was blank. This was signed by the client on 2-4-11.
This was discussed and confirmed with the facility director and the clinical supervisor on May 12, 2011.
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Plan of Correction
Nursing supervisor will conduct a brief training on proper consent completion by 6/30/2011. Charts will be monitored by medical records department to ensure that consents are completed in full. Monitoring will continue monthly until benchmark of 100% is met for 90 days. Program Director will monitor completion. |
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 the review of patient records, the facility failed to document an attempt to follow up on a client in five out of five client records reviewed.
The findings include:
Fourteen client records were reviewed on May 12, 2011. Five of the fourteen client records were detoxification records. Facility policy states a follow up attempt will be completed within seven days after discharge. Five of the client records were required to document a client follow up attempt or contact. Five out of five client records do not include documentation of a follow up attempt or contact.
Client record #10 - Client was admitted on 2-1-11 and discharged on 2-6-11. A follow-up attempt was due by 2-13-11. There is no documentation of a follow up attempt as of
5-12-11.
Client record #11 - Client was admitted on 3-24-2011 and discharged on 3-29-11. A follow-up attempt was due by 4-5-11. There is no documentation of a follow up attempt as of 5-12-11.
Client record #12 - Client was admitted on 3-7-11, and discharged on 3-11-11. A follow-up attempt was due by 3-18-11. There is no documentation of a follow up attempt as of 5-12-11.
Client record #13 - Client was admitted on 4-7-11, and discharged on 4-12-11. A follow-up attempt was due by 4-19-11. There is no documentation of a follow up attempt as of 5-12-11.
Client record #14-Client was admitted on 2-4-11, and discharged on 2-9-11. A follow-up attempt was due by 2-16-11. There is no documentation of a follow up attempt as of 5-12-11.
This was discussed and confirmed with the clinical supervisor on May 12, 2011.
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Plan of Correction
Program Director will designate an individual on staff to conduct and document all follow-up calls. Calls will be made in timely fashion and prior to the 8th day after discharge. Follow-up calls will be monitored in closed chart monitors to guarantee protocol is being followed. Continuous monthly monitoring will occur until a bench mark of 100% is met for 90 days. |