INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17-18, 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
The facility failed to ensure that stairways from the nonresidential facility were unobstructed.
A physical plant inspection was conducted on September 17, 2019. At the time of the inspection, one of the stairways was found to be blocked by various items sitting on the stairs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The stairway that was found to be obstructed is not a stairway that is utilized as an established exit by the Bartonsville office. As a result, administrative assistant placed a "No Exit" sign on the door on 9/18/19. Additionally, Program Director has collaborated with maintenance and will have the Emergency Exit Sign removed by November 1, 2019 to prevent any indication that this door is an available exit. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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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 Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The client's rights form within the EMR was amended and became active on 9/23/19. It now includes all required areas. Staff received notification of the change on 9/18/19. |
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 September 17-18, 2019, the facility failed to provide documentation that the client was notified of their rights in seven of seven client records reviewed. Clients are provided a handbook to include client rights. The handbook does not contain:
709.30 (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.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The client's rights form within the EMR was amended and became active on 9/23/19. It now includes all required areas. Staff received notification of the change on 9/18/19. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
The facility failed to file an unusual incident report within 3 business days following a client death.
A review of unusual incident reports took place on September 17, 2019, during an onsite inspection. There was an unusual incident report documented for a client death on March 18, 2019; however, there was no documentation that the report was sent to DDAP.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were trained on October 14, 2019 on the existing policy about internal incident reporting and will complete an internal incident report within 24 hours of the event. This will be submitted to the program director who will determine the need for a DDAP report and complete the appropriate UIR within the required timeframes. Program Director will be responsible for monitoring compliance. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to file an unusual incident report within 3 business days following an event requiring the presence of an ambulance.
A review of unusual incident reports took place on September 17, 2019, during an onsite inspection. There was an unusual incident report documented for an ambulance onsite on February 22, 2019; however, there was no documentation that the report was sent to DDAP.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were trained on October 14, 2019 on the existing policy about internal incident reporting and will complete an internal incident report within 24 hours of the event. This will be submitted to the program director who will determine the need for a DDAP report and complete the appropriate UIR within the required timeframes. Program Director will be responsible for monitoring compliance. |