INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 19-21, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pyramid Healthcare Inc. Pyramid Pittsburgh was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based on the Behavioral Health Tech (BHT) staffing report on May 28, 2021, the facility failed to ensure they had sufficient coverage during the 7pm to 7am shifts for the following days: 4/25/21, 4/26/21, 4/27/21, 4/28/21, 4/29/21, 4/30/21 and 5/1/21. During this time period only one BHT was working during that shift.
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Plan of Correction
New BHT Manager has been assigned to the department and has been made aware of scheduling needs. BHT Manager is also being trained on July 1 on utilizing electronic scheduling system (Ability) to ensure all shifts are covered. BHT supervisors have also been made aware that when shifts are not covered, they must assume the role and fill in when needed. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of facility staff trainings hours for training year 2020 on May 28, 2021, the facility failed to ensure that the PD obtained the required 12 hours of training.Employee #8 hired 7/1/19
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Plan of Correction
All supervisors will now be held responsible for ensuring their staff complete training as required. Supervisors will check online training system (Relias) monthly and review during supervision with staff.
Staff #8 will have the training completed by July 31, 2021.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of staff training hours for training year 2020 on May 28, 2021, the facility failed to ensure that the following staff completed the required training.Employee #9 hired 1/14/2019 obtained 1.75 hrs.Employee #10 hired 2/22/16 obtained 12.25 hrs.Employee #11 hired 1/19/18 obtained 12 hrs.Employee # 12 hired 8/19/19 obtained 21.25 hrs
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Plan of Correction
All supervisors will now be held responsible for ensuring their staff complete training as required. Supervisors will check Relias training system monthly and review during supervision with staff.
Staff listed will have all trainings completed by July 31, 2021.
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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on the review of the facility's Staffing Requirement Facility Summary Report on 5/28/2021, the facility failed to ensure they had the number of required primary staff for every 7 clients.The following schedules dates were reviewed and missing primary care staff:4/18/21 - 4/24/214/19/21 - census 22 clients and only 3 primary care staff on each shift from 12am to 12am the next day.4/25/21 to 5/1/214/15/21 - census 16 clients and only 2 primary care staff worked during the 12am to 7am shift.5/2/21 to 5/8/215/6/21 - census 22 clients and only 3 primary care staff worked during the 12am to 7am shift.5/9/21 to 5/18/215/2/21 - census 22 only 3 primary care staff worked during the 12am to 7am shift.11/2/20 to 11/7/2011/4/20 - census 16 clients and only 2 primary care staff worked during the 12am to 7am shift.11/29/20 to 12/5/2012/2/20 - census 17 clients and only 2 primary care staff worked during the 1am to 7am shift and only 2 on the 8am to 8am shift (1 hour).12/21/20 to 1/2/2112/30/20 - census 18 clients and only 2 primary care staff worked during the 12am to 7am shift. 1/2/21 - census 16 clients and only 2 primary care staff worked 12am to 7am shift.
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Plan of Correction
New BHT Manager has been assigned to the department and has been made aware of scheduling needs.
By July 1, 2021, Nurse Managers and BHT Manager are expected to be utilizing electronic scheduling system, Ability, to ensure all shifts are covered. Supervisors have also been made aware that when shifts are not covered, they must assume the role and fill in when needed.
Pyramid Pittsburgh is bringing on a Director of Nursing (DON) in July 2021 to help ensure consistency and provide overall supervision in our medical department.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection conducted on May 19, 2021, the facility failed to ensure the facility was clean, safe, sanitary and in good repair at all times.- electronic jack cover is hanging from the outlet in the conference room behind the reception desk.-window screens with holes were found in office # 115, 2nd floor female lounge and 1st floor laundry room-peeling paint in room 116- thermostat covers were missing from room #'s 119, 249, 234, office # 107, and 2nd floor female unit nurses' station- window blind located in the stairwell off the 1st floor female unit has a hole in it- baseboard is peeling off the wall and laying on the floor in the hallway between the kitchen and the 1st floor female unit- "basement" elevator is missing a light cover on the down arrow- cracked window found in 2nd floor female unit stairwell and 3rd floor male unit medical lounge - hole in the wall off 3rd floor men's unit laundry room- light switch cover missing from office # 107
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Plan of Correction
Electronic jack cover, window screens, peeling paint, thermostat covers, window blind, and light switch covers missing have all been corrected.
Cracked window and hole in the wall are being addressed and will be completed by July 31, 2021.
Ongoing maintenance will be monitored by our monthly facility plant inspection and documented to ensure all maintenance items are addressed.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on the physical plant inspection conducted on May 19, 2021, the facility failed to ensure that all trash is stored in noncombustible containers. Garbage was on steps leading to basement level, outside of facility
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Plan of Correction
Garbage was immediately removed from the stairs.
All housekeeping/maintenance staff were addressed as to how to correctly dispose of all garbage on 6/4/2021.
This will be reviewed by Maintenance Supervisor with all staff during monthly staff meetings.
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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection conducted on May 19, 2021, the facility failed to ensure that facility furniture is in a state of good repair.There was ripped and worn furniture found in the 1st floor NA group room, 2nd floor female unit resource room, 2nd floor female lounge and the 2nd floor male lounge
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Plan of Correction
The furniture will be replaced by August 31, 2021. Inspection of furniture will be included into our monthly facility plant inspection and documented to ensure all furnishings are in a state of good repair. Any furnishings present that are not in a state of good repair will be replaced.
Leadership was reminded on 6/22/21 that if anyone notices any destruction/wear of furniture, that needs reported immediately to Maintenance Supervisor.
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705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection conducted on May 19, 2021, the facility failed to ensure that facility furniture is in a state of good repair.There was ripped and worn furniture was observed in the transortation office, 3rd floor detox unit 1 nurses station and the kitchen office. There is also a chair with no seat near the basement exit outside the staff breakroom
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Plan of Correction
The furniture will be replaced by August 31, 2021. Inspection of furniture will be included into our monthly facility plant inspection and documented to ensure all furnishings are in a state of good repair. Any furnishings present that are not in a state of good repair will be replaced.
Leadership was reminded on 6/22/21 that if anyone notices any destruction/wear of furniture, that needs reported immediately to Maintenance Supervisor.
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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
Based on a physical plant inspection conducted on May 19, 2021, the facility failed to ensure that each restroom had hot and cold water.A bathroom located outside the 1st floor intake suite has no water coming out of the faucet when the hot water spigot is turned on.
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Plan of Correction
Faucet was immediately fixed by Maintenance Supervisor.
Ongoing maintenance will be monitored by our monthly facility plant inspection and documented to ensure all maintenance items are addressed.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on May 19, 2021, the facility failed to ensure that the restroom was ventilated by either an exhaust fan or window.-exhaust fans were not functioning in the following bathrooms: Employee bathroom in basement outside the breakroom, Room #/s 115, 116, 117, 118, 119, 120,210, 222, 223, 224, 225, 228, 229, 238, 239, 240, 241, 242, 243, 244, 245, 246, 249,329, 330, 331, 343, 344, 348, 349, 350, office #'s 106 and 107, detox unit 2 nurses station, 2nd floor men's unit tech office, detox lounge, 3rd floor men's medical lounge and the Executive Director's office - exhaust vent taped shut in office # 341
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Plan of Correction
Exhaust fans were all controlled by the same unit. This unit was fixed immediately by Maintenance Supervisor.
Tape was removed from exhaust fan in office #341.
Ongoing maintenance will be monitored by our monthly facility plant inspection and documented to ensure all maintenance items are addressed.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on May 19, 2021, the facility failed to maintain each bathroom in a functional, clean and sanitary manner.- vent covers missing in room #'s 227 and 317- ceiling tile that contains vent cover is split in room # 320- appearance of dark spots running down the 3rd stall on the right in shower room # 2 of 2nd floor men's unit. Leftover caulk from where a door may have been installed previously is black
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Plan of Correction
Vent covers have been replaced, ceiling tile has been replaced, and shower items have been cleaned. All items were completed by June 29, 2021.
Housekeeper Supervisor job has been posted to help manage the cleanliness of the property. This position is expected to be filled by August 31, 2021. This role will take over the responsibilities currently under Maintenance Supervisor to assist in oversight.
Ongoing maintenance will be monitored by our monthly facility plant inspection to ensure all maintenance items are addressed.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection conducted on May 19, 2021, the facility failed to ensure that provide thermometers in each refrigerator.Thermometers were missing from 2 refrigerators and 1 stand alone freezer located in the 3rd floor detox storage room beside the nurses station.
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Plan of Correction
Thermometers were placed in both refrigerators and the freezer on June 4, 2021.
Kitchen Manager will check and document all refrigerators/freezers monthly to ensure they thermometers are placed and working properly.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted on May 19, 2021, the facility failed to ensure that there were no portable heaters at the facility. Portable heaters were found in the 2nd intake office on the 1st floor and in office # 211.
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Plan of Correction
By June 1, 2021, Portable heaters were removed from offices and all staff were addressed regarding space heater requirements (must be mounted/installed).
This will be monitored by our monthly facility plant inspection and documented to ensure no space heaters are used inappropriately.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the facility's trainings, on May 28, 2021, the facility failed to ensure that all staff obtained the required training. #1 hired 11/30/20 and the training certificate has the date of completion of 12/14/20#13 hired 4/19/21 no certificate documented for review#14 hired 3/6/21 and the training certifcate has the date of completion of 3/15/21
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Plan of Correction
All supervisors will now be held responsible for ensuring their staff complete training as required. Supervisors will check trainings on our online training system (Relias) monthly and review individually with staff.
Staff #13 will have training completed by July 31, 2021.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the facility's trainings, on May 28, 2021, the facility failed to ensure that all staff obtained the required training. #1 hired 11/30/20 and the training certificate has the date of completion of 12/14/20#13 hired 4/19/21 no certificate documented for review#14 hired 3/6/21 and the training certificate has the date of completion of 3/15/21
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Plan of Correction
June 22, 2021 leadership meeting, All supervisors were directed that they will now be held responsible for ensuring their staff complete training as required. Leadership will review staff trainings monthly to ensure they are being completed in a timely fashion.
Staff #13 will have training completed by July 31, 2021. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill log on May 28, 2021, the facility failed to include on the form the following.Problems Encountered
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Plan of Correction
Fire drill documentation was reviewed with Maintenance Supervisor on June 15, 2021 and reminded to complete in its entirety.
Documentation will be reviewed monthly for accuracy by leadership.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire dill log on May 28, 2021, the facility failed to document the alternate exit route on the following days.The alternate route was not documented for the following months: 4/27/21, 3/10/21, 1/18/21 and 12/30/20.
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Plan of Correction
Fire drill documentation was reviewed with Maintenance Supervisor on June 15, 2021, and reminded to complete in its entirety.
Documentation will be reviewed monthly for accuracy by leadership.
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire dill log on May 28, 2021, the facility failed to document that the fire alarm or smoke detector was set off during each fire drill. This requirement was not documented during the following months: 1/18/21 & 11/26/20. Also, on the form it checked that the alarm was set off, but then it states the Air Horn was used: 4/27/21, 3/10/21 and 2/24/21.
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Plan of Correction
Fire drill documentation was reviewed with Maintenance Supervisor on June 15, 2021, and reminded to complete in its entirety.
Documentation will be reviewed monthly for accuracy by leadership.
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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
Based on a review of client records on May 19-21, 2021, the facility failed to obtain a vailed consent in 1 of 12 records reviewed, #11.The facility documented on the call log in the client's record that a recovery house was contacted regarding coordination of care for the client, but there was no consent for this agency in the record.
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Plan of Correction
Clinical Director on 6/25/21, reminded all clinical staff, including intake, of the requirement and necessity of appropriate consents and dates.
Clinical Director and Clinical Supervisors will review consents during weekly chart audits to ensure compliance.
RQM will monitor for compliance during KPI monthly audits. If discrepancies are found, disciplinary actions will follow for counselors noted.
If the issues continues, all staff will be required to attend a confidentiality/ROI training.
IT will do monthly checks of all signature pads to ensure they are working correctly.
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709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records on May 19-21, 2021, the facility failed to document a valid consent in 1 of 12 records reviewed, #10 and #11.Client # 10 - Consent dated 5/16/21 for the SCA was missing the name, address, and phone number of the agency.Client # 11 - Consent dated 5/19/21 had the name of the agency as "other."
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Plan of Correction
On 6/25/21, Clinical Director reminded all clinical staff, including intake, of the requirement and necessity of appropriate consents along with ensuring they are completed fully.
Clinical Supervisors/Clinical Director will look specifically for these consents during weekly chart audits to ensure they are being completed.
RQM will monitor for compliance during KPI monthly audits.
If the issues continues, all staff will be required to attend a confidentiality/ROI training.
IT will do monthly checks of all signature pads to ensure they are working correctly.
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709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records on May 19-21, 2021, the facility failed to document a valid consent in 2 of 12 client records reviewed, # 10 and # 12.Client # 10 - all consents are signed by the client but there is no date indicating when the client signed. Client # 12 - the consent dated 5/20/21 for an inpatient facility was not signed or dated by client.
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Plan of Correction
On 6/25/21, Clinical Director reminded all clinical staff, including intake, of the requirement and necessity of appropriate consents along with ensuring they are completed fully.
Clinical Supervisors/Clinical Director will look specifically for these consents during weekly chart audits to ensure they are being completed.
RQM will monitor for compliance during KPI monthly audits. If discrepancies are found, disciplinary actions will follow for counselors noted.
If the issues continues, all staff will be required to attend a confidentiality/ROI training.
IT will do monthly checks of all signature pads to ensure they are working correctly.
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709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records on May 19-21, 2021, the facility failed to document a valid consent in 1 of 12 client records reviewed, #10.Client # 10 - all consents are missing the dates when the witness signed those consents.
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Plan of Correction
On 6/25/21, Clinical Director reminded all clinical staff, including intake, of the requirement and necessity of appropriate consents along with ensuring they are completed fully.
Clinical Supervisors/Clinical Director will look specifically for these consents during weekly chart audits to ensure they are being completed.
RQM will monitor for compliance during KPI monthly audits. If discrepancies are found, disciplinary actions will follow for counselors noted.
If the issues continues, all staff will be required to attend a confidentiality/ROI training.
IT will do monthly checks of all signature pads to ensure they are working correctly.
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709.28 (c) (6) 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 must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records on May 19-21, 2021, the facility failed to document a valid consent in 1 of 12 client records reviewed, #7.Client # 7 - All consents dated 4/23/21 were missing an expiration date. These consents included three funding sources, a medical facility, two psychiatric facilities and an emergency contact.
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Plan of Correction
On 6/25/21, Clinical Director reminded all clinical staff, including intake, of the requirement and necessity of appropriate consents along with ensuring they are completed fully.
Clinical Supervisors/Clinical Director will look specifically for these consents during weekly chart audits to ensure they are being completed.
RQM will monitor for compliance during KPI monthly audits.
If the issues continues, all staff will be required to attend a confidentiality/ROI training.
IT will do monthly checks of all signature pads to ensure they are working correctly.
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on the interviews with facility staff and clients, during the complaint investigation on May 19-21, 2021, the facility failed to have qualified staff administering medication.The Medical Behavioral Techs (MBT) are administering the client's medication when they are only supposed to give the clients their medication. The MBT's are opening the medication bottles or packs, then giving it to the clients. During the interviews it was explained that they also are not wearing gloves when handling the client's medication.
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Plan of Correction
On 6/3/2021 and again on 6/28/2021 all MA's/Med Techs were re-educated by Nurse Manager on appropriate medication administration.
Ongoing monthly meetings/discussions will be held to ensure all staff are maintaining appropriate protocol.
ED has begun to assist in oversight in disciplinary actions.
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709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on the interviews with facility staff and clients, during the complaint investigation on May 19-21, 2021, the facility failed to document medication errors.During the interviews it was discovered that on several occasions (they could not remember the dates) clients were given the wrong medication and or the dose was not correct.
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Plan of Correction
Nurse Managers reviewed in staff meetings in June, which will continue monthly, the importance of reporting medication errors.
Pyramid Pittsburgh is bringing on a Director of Nursing (DON) in July 2021 to help ensure consistency and provide overall supervision in our medical department.
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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
Based on a review of client records, May 19-21, 2021, the facility failed to provide a notice of termination in record #10.Client # 10 was behaviorally discharged on 5/19/21 and a termination letter was not documented in the record.
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Plan of Correction
On June 25, 2021, Clinical Director reviewed with clinical staff the need for appropriate documentation of the termination letter in client chart.
Clinical Director and Clinical Supervisors will review consents during weekly chart audits to ensure compliance.
RQM will monitor for compliance during KPI monthly audits. If discrepancies are found, disciplinary actions will follow for counselors noted.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, May 19-21, 2021, the facility failed to provide a notice of termination that provided the client with the opportunity to request reconsideration of a decision terminating treatment in record #10.Client # 10 was behaviorally discharged on 5/19/21 and a termination letter was not documented in the record.
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Plan of Correction
On June 22, 2021, all leadership staff were reminded of the need for appropriate documentation of the termination letter in client chart.
Clinical Director and Clinical Supervisors will review consents during weekly chart audits to ensure compliance.
RQM will monitor for compliance during KPI monthly audits. If discrepancies are found, disciplinary actions will follow for counselors noted.
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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
Based on a review of the facility's unusual incidents, that occurred during the compliant investigation and full inspection, on May 19 through 21, 2021 and May 28, 2021, the facility failed to either report the unusual incident or did not report within the required 3-day time frame. - received 2/23/21 to DDAP- received 3/24/21 to DDAP- received 3/24/21 to DDAP- received 3/24/21 to DDAP
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Plan of Correction
On June 22, 2021, all leadership staff were reminded of the regulation of submitting incident reports within the 3 business day time-frame.
Leadership will also be retrained on Unusual Incident Reporting by August 31, 2021.
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709.62(c)(3)(i) LICENSURE Medical history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of the facility's detox client records on May 19-21, 2021, the facility failed to document a medical history within the required timeframe in 2 of 6 records reviewed. The facility policy and procedure states that histories will be completed within 72 hours after admission. Client # 2 was admitted on 11/25/20 and there was no documentation of the client's medical history. Client # 12 was admitted on 5/18/21 and there was no update from his last detox admission of 4/6/21.
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Plan of Correction
Clinical Director reviewed on 6/25/21 with Assessment Counselors the requirements of appropriate documentation at intake.
RQM Team will conduct monthly audits to monitor this item specifically. It will be calculated in monthly KPI audits. ED and CD will follow up with appropriate assessment counselors.
Intake Supervisor position is being created/posted to ensure compliance and oversight in the department. Expectation is to have position filled by August 31, 2021.
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709.62(c)(3)(ii) LICENSURE D & A History
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of the facility's detox client records on May 19-21, 2021, the facility failed to document a drug and alcohol history within the required timeframe in 2 of 6 records reviewed. The facility policy and procedure states that histories will be completed within 72 hours after admission. Client # 2 was admitted on 11/25/20 and there was no documentation of the client's drug and alcohol history. Client # 12 was admitted on 5/18/21 and there was no update from his last detox admission of 4/6/21.
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Plan of Correction
Clinical Director reviewed on 6/25/21 with Assessment Counselors the requirements of appropriate documentation at intake.
RQM Team will conduct monthly audits to monitor this item specifically. It will be calculated in monthly KPI audits. ED and CD will follow up with appropriate assessment counselors.
Intake Supervisor position is being created/posted to ensure compliance and oversight in the department. Expectation is to have position filled by August 31, 2021.
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709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of the facility's detox client records on May 19-21, 2021, the facility failed to document a personal history within the required timeframe in 2 of 6 records reviewed. The facility policy and procedure states that histories will be completed within 72 hours after admission. Client # 2 was admitted on 11/25/20 and there was no documentation of the client's personal history. Client # 12 was admitted on 5/18/21 and there was no update from his last detox admission of 4/6/21.
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Plan of Correction
Clinical Director reviewed on 6/25/21 with Assessment Counselors the requirements of appropriate documentation at intake.
RQM Team will conduct monthly audits to monitor this item specifically. It will be calculated in monthly KPI audits. ED and CD will follow up with appropriate assessment counselors.
Intake Supervisor position is being created/posted to ensure compliance and oversight in the department. Expectation is to have position filled by August 31, 2021.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of the facility's detox client records on May 19-21, 2021, the facility failed to document a psychosocial evaluation within the required timeframe in 2 of 6 records reviewed. The facility policy and procedure states that psychosocial evaluations will be completed within 72 hours after admission. Client # 2 was admitted on 11/25/20 and there was no documentation of the client's psychosocial evaluation. Client # 12 was admitted on 5/18/21 and there was no documentation of the client's psychosocial evaluation.
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Plan of Correction
Clinical Director reviewed on 6/25/21 with Assessment Counselors the requirements of appropriate documentation at intake.
RQM Team will conduct monthly audits to monitor this item specifically. It will be calculated in monthly KPI audits. ED and CD will follow up with appropriate assessment counselors.
Intake Supervisor position is being created/posted to ensure compliance and oversight in the department. Expectation is to have position filled by August 31, 2021.
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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
Based on a review of client records on May 19-21, 2021, the facility failed to show documentation of the client's emergency contact in record #10.Client # 10 was admitted on 5/17/21.
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Plan of Correction
Intake staff will be educated at next staff meeting (July 31, 2021) on all clients eligibility for admissions and all appropriate documentation needed including emergency contact.
Intake Supervisor position is being created/posted to ensure compliance and oversight in the department. Expectation is to have position filled by August 31, 2021.
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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
Based on a review of client records on May 19-21, 2021, the facility failed to document a follow-up attempt in three of six client records reviewed. Per the facility's policy and procedures, follow-up attempts are completed 7 days after discharge.Client #4 was discharged on 1/2/21.Client #5 was discharged on 4/9/21.Client #6 was discharged on 12/11/20.
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Plan of Correction
Clinical Director addressed in June clinical supervision with counseling staff that follow-ups MUST be completed 7 days after discharge. Clinical Supervisors will be monitors during weekly chart audits.
There is new documentation within our online system that will prompt contact within 7 days.
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