INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and buprenorphine monitoring inspection. The inspection was conducted on September 2-3, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Pyramid Healthcare, Inc was found not to be in compliance with the applicable chapters of 4 PA Code and 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 received 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 in 5 of 7 personnel records.
The findings include:
Eighteen personnel records were reviewed on August 31- September 1, 2015. Seven personnel records were reviewed for compliance with the HIV/AIDS and STD/TB training. There was no documentation of the HIV/AIDS and STD/TB training in personnel 13, 14, 15, 16 and 17.
Employee # 13 was hired as a maintenance person on October 2, 2012. The HIV/AIDS and STD/TB training was to be completed by October 2, 2014. There was no documentation provided that the employee completed the training.
Employee # 14 was hired as housekeeping staff on November 4, 2011. The HIV/AIDS and STD/TB training was to be completed by November 4, 2013. There was no documentation provided that the employee completed the training.
Employee # 15 was hired as housekeeping staff on June 17, 2013. The HIV/AIDS and STD/TB training was to be completed by June 17, 2015. There was no documentation provided that the employee completed the training.
Employee # 16 was hired as housekeeping staff on May 13, 2013. The HIV/AIDS and STD/TB training was to be completed by May 13, 2015. There was no documentation provided that the employee completed the training.
Employee # 17 was hired as dietary staff on April 24, 2012. The HIV/AIDS and STD/TB training was to be completed by April 24, 2014. There was no documentation provided that the employee completed the training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employees #13, # 14, # 15, #16, and # 17 will complete HIV/AIDS and STD/TB training by 12/21/2015. They will submit certificates of completion to Pyramid's Human Resources Department by 12/28/15. Employees' supervisors will ensure that they attend these trainings in a timely manner and obtain copies of their certificates. The Human Resources Department will verify that these expectations have been met by auditing the personnel records of these employees by 12/31/15. Human Resource Coordinators will monitor employee files on a quarterly basis to ensure that all staff receive the required training within the required timeframe.
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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 an inspection of the physical plant, the facility failed to provide documentation of frozen food being stored at or below 0 degrees.
The findings include:
The physical plant inspection was conducted on September 2, 2015. The inspection of the kitchen area found that the thermometer in the first freezer showed the temperature to be at 14 degrees. A review of the freezer log for the month of August 2015, showed that the first freezer was above 0 degrees on August 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 16, 17, 18, 19, 20, 22, 23, 30 and 31, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility Dietary Supervisor will ensure that freezer temperatures are at or below 0 degrees Fahrenheit. Dietary personnel will monitor and log these temperatures on a daily basis and will inform the Maintenance Supervisor of any temperature readings above 0 degrees Fahrenheit. The facility Maintenance Supervisor will ensure regular maintenance is performed on all refrigerators.
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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 shall be in writing and shall 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, the facility failed to obtain a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in one of sixteen client records. In addition, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when releasing information to an insurance company in one of sixteen client records.
The findings include:
Sixteen client records were reviewed on September 2 - 3, 2015. Sixteen client records were required to include documentation of written, informed and voluntary consents from the client. 4 Pa. Code 255.5 restricts the information to be released to insurance companies to the following: whether or not the client is in treatment, client's prognosis, the nature of the project, a brief description of the client's progress and a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse. The facility failed to obtain a written, informed and voluntary consent from the client prior to disclosing information contained in client record # 7. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 when releasing information to an insurance company in client record # 7.
Client # 7 was admitted into treatment on January 6, 2015 and discharged on March 27, 2015. A fax was sent to an insurance company on March 26, 2015 and included the name, date of birth and prior medications of the client. There was no documentation of a written consent to release information to this insurance company as of September 3, 2015. The facility failed to obtain a written, informed and voluntary consent to release information prior to disclosing information contained in the record of client # 7. In addition, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when releasing the prior medications of client # 7 to an insurance company.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All facility staff will ensure that a release of information is signed by a client prior to releasing any information regarding that client. This will be monitored by monthly chart audits by departmental supervisors. All facility staff that work directly with clients, and are in a position to request that a client sign a release of information, will be re-trained on 255.5 regulations regarding the releasing of client information. The program director for the facility will ensure that all applicable staff are re-trained regarding these regulations. |
709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on the review of unusual incident reports, the facility failed to comply with a directive issued by the Department regarding the reporting of the unusual incidents.
The findings include:
The unusual incident reports were reviewed on September 3, 2015. Two unusual incident reports documented that an ambulance had been called to the facility. These reports were to have been reported to the Department within three business days.
There was no documentation that the unusual incident reports, dated 7/13/15 and 8/18/15, where an ambulance had been called to the facility, were reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Unusual Incidents requiring the presence of police, fire, or ambulance/emergency personnel will be completed and submitted to the Department within three business days of a reportable event. The facility?s Nurse Manager will ensure completion of these reports by on-site Nursing staff and the facility?s Risk Manager will ensure that these incidents are reported to the Department within three business days. The facility Risk Management Committee will review all incident reports on a monthly basis and verify that all applicable reports were sent to DDAP. |