INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29, 2015 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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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 the review of personnel records, the facility failed to document that staff persons completed HIV/AIDS and STD/TB/Other Health Related Topics training in nine of seventy-eight personnel records.
The findings include:
Personnel records were reviewed on September 29, 2015. Seventy-eight personnel records were reviewed for the completion of HIV/AIDS and STD/TB/Other Related Health Topics training. This training was not documented in nine of seventy-eight personnel records.
Employee # 1 was hired on 7/30/13 and is employed in the housekeeping department. The HIV/AIDS and STD/TB/Other Related Health Topics training was due to be completed by 7/30/15. There was no documentation that the employee completed the training.
Employee # 2 was hired on 1/21/13 and is employed in the maintenance department. The HIV/AIDS and STD/TB/Other Related Health Topics training was due to be completed by 1/21/15. There was no documentation that the employee completed the training.
Employee # 3 was hired on 7/15/13 and is employed as a BHT Supervisor. The HIV/AIDS training was due to be completed by 7/15/15. There was no documentation that the employee completed the training.
Employee # 4 was hired on 7/1/13 and is employed as an Intake Coordinator Supervisor. The HIV/AIDS training was due to be completed by 7/1/15. There was no documentation that the employee completed the training.
Employee # 5 was hired on 9/3/13 and is employed in the housekeeping department. The HIV/AIDS and STD/TB/Other Related Health Topics training was due to be completed by 9/3/15. There was no documentation that the employee completed the training.
Employee # 6 was hired on 8/16/13 and is employed in the needs assessment department. The HIV/AIDS training was due to be completed by 8/16/15. There was no documentation that the employee completed the training.
Employee # 7 was hired on 7/5/13 and is employed as a Maintenance Manager. The HIV/AIDS and STD/TB/Other Related Health Topics training was due to be completed by 7/5/15. There was no documentation that the employee completed the training.
Employee # 8 was hired on 9/23/13 and is employed as a BHT. The HIV/AIDS training was due to be completed by 9/23/15. There was no documentation that the employee completed the training.
Employee # 9 was hired on 8/12/13 and is employed as a driver. The HIV/AIDS training was due to be completed by 8/12/15. There was no documentation that the employee completed the training.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation for the facility. The facility was cited for non-compliance of this standard during the previous licensing renewal inspection, which was completed on September 10, 2014.
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Plan of Correction
Pyramids HR Regional Coordinator has developed a training data base specific to each facility to document/track initial and ongoing training requirements for staff. This information is now being forwarded to the facilities Office Manager who in turn is sending email notifications to all Supervisors regarding staff training requirements and dates of available trainings.Supervisors will review training needs with respective staff as part of their individual supervision to ensure compliance.
Employee #1 will attend the following:
HIV - October 20, 2015 Lehigh County Govt. Center
TB/STD October 29, 2015 or December 10, 2015 at Hillside facility.
Employee #2 will attend the following:
HIV - October 20, 2015 Lehigh County Govt. Center
TB/STD October 29, 2015 or December 10, 2015 at Hillside facility.
Employee #3 will attend the following:
HIV - October 20, 2015 Lehigh County Govt. Center
Employee #4 will attend the following:
HIV - October 20, 2015 Lehigh County Govt. Center.
Employee #5 will attend the following:
HIV - October 20, 2015 Lehigh County Govt. Center.
TB/STD -October 29, 2015 or December 10, 2015 at the Hillside facility.
Employee #6 will attend the following:
HIV - December 4, 2015 at Eagleville Hospital
Employee #7 will attend the following:
HIV- October 20, 2015 Lehigh County Govt. Center.
TB/STD - October 29,2015 or December 10, 2015 at Hillside facility.
Employee #8 will attend the following:
HIV - October 20, 2015 Lehigh County Govt.Center.
Employee #9 will attend the following:
HIV - October 20, 2015 Lehigh County Govt. Center.
Target date for completion: December 11, 2015. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and CPR certification cards, the project failed to ensure that staff persons obligated to complete CPR certification training had received acceptable CPR certification.
The findings include:
Seventy-eight personnel records were reviewed for the completion of acceptable CPR certification on September 29, 2015. The project failed to to ensure that the facility's two van drivers received acceptable CPR certification. The facility confirmed that both van drivers currently transport clients alone.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation for the facility. The facility was cited for non-compliance of this standard during the previous licensing renewal inspection, which was completed on September 10, 2014.
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Plan of Correction
Pyramids HR Regional Coordinator had developed a training data base for the facility to document/track initial and ongoing training requirements for all staff. HR Coordinator forwards this data base to the facilities Office Manager. The Office Manager will send email notification to all Supervisors of staff training requirements and the available training dates and sites they are offered. Supervisors will review training needs with their respective staff as part of individual supervision to ensure compliance.
The two identified Pyramid transportation staff who require CPR certification have been registered to participate on November 3, 2015 at Pyramids Outpatient office in Allentown, Pa.
Target date for completion is November 4, 2015. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of patient records, the facility failed to document that a physical examination, completed by a physician assistant, was countersigned by the medical director in one of three patient records.
The findings include:
Three detox records were reviewed on September 29, 2015. The facility failed to document that a physical examination, completed by the physician assistant, was countersigned by the medical director in patient record # 2.
Patient # 2 was admitted into detox treatment on 9/24/15. The physical examination, completed by the physician assistant 9/25/15, was not countersigned by the medical director.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon completion of a physical exam, the Physician Assistant will print out a copy of the document and forward accordingly to the facility Medical Director for signature. Nurse Manager will monitor this process on the days the Physician Assistant is working. Once documents are signed, they will be scanned into the electronic chart by the Medical Secretary to ensure compliance. On October 1, 2015 facility requested the electronic record be adjusted to allow for the Physician Assistant to electronically route the document directly to Medical Director who in turn will receive an electronic alert that will trigger her to sign the document.
Target date for implementation of the signature process is October 5, 2015. |
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
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for detoxification treatment in one of three patient records reviewed.
The findings include:
Three patient records requiring informed, voluntary, written consent to treatment prior to the administration of a narcotic agent were reviewed on September 29, 2015. The facility failed to document the completion of an informed, voluntary, written consent that includes the required content specified in prior to the administration of the narcotic agent Subutex in patient record # 3.
Patient # 3 was admitted into detox treatment on 8/7/15 and was discharged from detox on 8/12/15. The patient received their initial dose of Subutex on 8/8/15, at 12 am. The facility failed to document informed, voluntary, written consent for Subutex treatment in the patient's record prior to the administration of Subutex. The patient's record documented a patient consent form that was signed and dated by the client on 8/11/15.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure compliance with respect to documenting informed, voluntary written consent for subutex treatment prior to the administration of subutex.
Charge Nurses on the overnight shift will review all discharge records from the day to ensure all documentation is complete before closing the record.
Nurse Manager will facilitate weekly open and closed chart audits to ensure compliance.
Target date for implementation is October 5, 2015. |