INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on November 7-10 & November 17, 2016 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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705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
The facility failed to ensure hot water temperatures did not exceed 120 degrees in all bathrooms.
A physical plant inspection was conducted on November 9, 2016. The water temperatures in the follow rooms exceeded 120 degrees:
Room #117 bathroom water temperature was 125.5 degrees.
Room #118 bathroom water temperature was 126 degrees.
Room #119 bathroom water temperature was 124.2 degrees.
Room #122 bathroom water temperature was 121.7 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility maintenance department will conduct a monthly check of the temperatures on each unit and record results in log. The log will be available for inspection or review at our monthly Performance Improvement Meetings and plans of correction will be required with any variation from the 120 degree temperature. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
A physical plant inspection was conducted on November 9, 2016. During the physical plant inspection, it was observed that a magnetic lock was present on the door at exit 98 E from the women's floor stairwell, which also provides an exit from the men's floor above. On November 10, 2016, the alarm was set off to determine if the magnetic lock releases for emergency evacuation. The magnetic lock did not release when the alarm was activated, and the exit remained obstructed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility maintenance department will include verification of the magnetic locks functionality with every fire drill each month and record if the door is working properly. Lack of function will be noted and corrected immediately upon discovery. The verification will be kept with the monthly fire drill logs for inspection/review. |
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
The facility failed to obtain informed and voluntary consent forms for the disclosure of information contained in the client record in twenty five of twenty five client records reviewed on November 9-10 and November 17, 2016.
Twenty five client records were reviewed. Twenty five records required an informed and voluntary consent to release client information. The facility failed to obtain an informed and voluntary consent to release information in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25.
The consent to release information form states that revocation must be in writing. 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.
In addition, consents to release information to criminal justice authorities were observed to include a statement that the consent could not be revoked. There were no court orders mandating treatment documented for these clients and therefore, the consents could be revoked verbally or in writing at any time.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent, including acknowledgement that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 2017. Completion of training will be verified by post test completion and monitored by Human resources Coordinators. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
The facility failed to document that a copy of signed consents were offered to the client in 25 of 25 client records.
Twenty five client records were reviewed on November 9-10 and November 17, 2016. All twenty five client records included at least one signed consent in which the client was not offered a copy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent, including acknowledgement that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 2017. Completion of training will be verified by post test completion and monitored by Human resources Coordinators. |
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 a written unusual incident report with the Department within 3 business days following an unusual incident involving the presence of ambulance personnel.
Ambulance personnel were called to the facility on 3/25, 4/11, 4/22, 5/8, 9/27 and 10/26, 2016. There was no documentation provided that an unusual incident report had been submitted to the Department as of November 10, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised unusual incident report policy on 11/27/16. All facility Directors received a copy of the updated policy and it was placed in the corporate policy and procedure manual. All staff members who deal directly with unusual incident reporting will receive additional training regarding unusual incidents and proper reporting procedures. Training will be concluded by February 2017. Completion of training will be verified by post test completion and monitored by Human resources Coordinators. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to document that an individual had been physiologically dependent for at least 1 year prior to admission for maintenance treatment in four of four patient records reviewed on November 9-10 and November 17, 2016.
Four patient records were reviewed as inpatient maintenance records. All the patient records required documentation of physiological dependency for at least 1 year. Patient records # 22 , 23, 24 and 25 did not include documentation of physiological dependency for at least 1 year prior to admission for maintenance treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our documentation of addiction form was amended to include physiological dependence for at least 1 year prior to admission for maintenance treatment for the prescriber to note at the time of signing. Staff responsible for the completion of this form will be re-trained on the form revision by the Director of Nursing by January 15, 2017. Monthly monitoring to ensure 100% compliance will be conducted through the use of monthly chart monitors completed by Program or Clinical Director. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
The facility failed to contact the previous narcotic treatment facility for the patient's treatment history in one of one patient record reviewed on November 9-10 and November 17, 2016.
Four patient records were reviewed as inpatient maintance records. One patient record required contacting the prior narcotic treatment facility for the previous treatment history.
There was no documentation in patient record #22 that the prior narcotic treatment facility had been contacted.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clients who are transferred or were in prior treatment will be asked to sign consents for records. Treatment staff will facilitate requesting all prior treatment records that impact the client's current needs once consent is signed. Records will be scanned or copied into our eCR records for each client. Staff will be re-trained on the proper completion of this activity as part of the intake process by the Clinical Director or Director of Nursing by January 15, 2017. Monthly monitoring to ensure 100% compliance will be conducted through the use of monthly chart monitors completed by Program or Clinical Director. |
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
The facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for maintenance treatment in four of four patient records reviewed on November 9-10 and November 17, 2016.
Four patient records were reviewed as inpatient maintenance records. All four were reviewed for the completion of an informed, voluntary written consent. There was no documentation of a written consent for maintenance treatment in patient records # 22, 23, 24, and 25.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients who are accepting maintenance treatment will have an informed, voluntary written consent signed prior to initiation of the treatment. The facility Medication Assisted Therapy Nurse/Case Manager will facilitate the consent signature. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to obtain a complete drug screen urinalysis prior to the administration of Subutex, a narcotic agent in three of six client records. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
Six Subutex detox client records were reviewed on November 9-10, 2016. All six client records were required to have documentation of a complete a drug screen urinalysis prior to the administration of Subutex, a narcotic agent. A complete urine drug screen includes receiving the results from a CLIA and Department of Health approved laboratory. The facility failed to obtain a complete drug screen urinalysis prior to the administration of Subutex, a narcotic agent in client records #1, 4 and 5.
The facility has Department of Health and CLIA certificates as a lab and can perform dipstick tests onsite; however, not all client records reviewed had documentation of a dipstick test performed onsite.
Client # 1 was admitted on 11/8/2016 and received their first dose of Subutex on 11/8/16. The urinalysis results were reported by the lab on 11/9/16. There was no dipstick test documented client record #1.
Client # 4 was admitted on 5/7/16 and received their first dose of Subutex on 5/8/16. The urinalysis results were reported by the lab on 5/10/16. There was one dipstick test documented in client record #4; however, it was not dated.
Client # 5 was admitted on 5/14/2016 and received their first dose of Subutex on 5/15/16. The urinalysis results were reported by the lab on 5/17/16. There was no dipstick test documented client record #1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Copies of all CLIA certified urine dipstick drug screens will be kept with the clients medication administration record for easy access and reference. The nurse administering the first dose will check to ensure the client has a dipstick on record prior to dosing the first dose of Subutex. The nurse who begins the Subutex will initial the CLIA certified urine dipstick screen indicating the test was done prior to dosing of Subutex. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The facility failed to document that it notified the transferring narcotic treatment program of the admission and initial dosing of the patient in 1 of 1 patient records reviewed on November 9-10 & 17, 2016.
Twenty five patient records were reviewed. One patient record was reviewed for documentation of the notification. There was no documentation in patient record # 22 that the transferring narcotic treatment program was notified of the transfer.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients who transfer/received to/from another narcotic treatment program for continued maintenance, detoxification or another treatment activity will have documentation of the event in their eCR record. Facility will develop a protocol regarding all clients who transfer/receive to/from another narcotic treatment program for continued maintenance, detoxification or another treatment activity. Protocol will include procedures to ensure appropriate staff are notified that the client has transferred from an existing narcotic treatment program. Protocol will further include initiation of a consent to: request the client's treatment records and communicate clients admit and date of initial/last dose in the current treatment activity. Written protocol and document for communication will be developed by January 15, 2017. Appropriate staff will be trained on the new protocol by Nurse Manager/Director of Nursing by January 31, 2017. Monthly chart monitors will be conducted by Clinical Director or Nurse Manager to ensure 100% compliance. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
The facility failed to provide complete policy and procedures addressing unusual incidents.
Administrative documentation that included the policy and procedure manual for the facility was reviewed on November 7-8, 2016. The policy addressing unusual incidents failed to include inappropriate behavior by a patient causing disruption to the narcotic treatment program and incidents with potential for negative community reaction.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy related to unusual incident reports was updated by the company VP of Clinical Services to include addition of "inappropriate behavior by a patient causing disruption to the narcotic treatment program and incidents with potential for negative community reaction." |