INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18-21, 2018, 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure that counseling sessions could not be seen from outside all of the counseling rooms.
Counseling office one hundred fourteen in the new women's building has a window with no coverings on it.
These findings were reviewed with facilty staff as part of the inspection process.
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Plan of Correction
The counseling office 114 in the C4 building has had window coverings placed over the windows in the office effective 7/21/18.
Clinical Supervisors will conduct random walk throughs of the clinical areas- weekly, to ensure that all windows remain covered where counseling occurs. |
709.32 (c) 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:
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Observations
At the time of the on-site inspection, the facility failed to implement all aspects of its medication policy.
The buprenorphine informed consent information packet that is given to patients at the facility reads, "If you are pregnant or lactating, buprenorphine cannot be used for detoxification or maintenance." The facility does provide buprenorphine maintenance to pregnant females.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The buprenorphine informed consent information packet that is given to patients at the faciity will be updated to reflect the following change:"If you are pregnant or lactation, buprenorphine may be used for detoxification or maintenance. The facility does provide buprenorphine maintenance to pregnant females.
All Nursing staff will be trained with regard to proper procedure concerning the execution of this consent.
The Nurse Manager or Assistant Nurse Manager will be repsonsible for said training no later than October 1, 2018. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to ensure that it educated all of its female patients of the possible risks to their unborn children from withdrawal from a narcotic administered or dispensed by the program.
There were five patient records reviewed where the facility was administering buprenorphine for detoxification or maintenance.
Patient #14 was first dosed with buprenorphine in inpatient non-hospital detoxification on April 20, 2018, and was subsequently dosed with buprenorphine in inpatient non-hospital detoxification and in inpatient non-hospital rehabilitation at the facility, but the patient was never given information about the risks of withdrawal from buprenorphine on unborn children.
Patient #15 was dosed with buprenorphine in inpatient non-hospital rehabilitation on May 8-9, 2018, but the patient was never given information about the risks of withdrawal from buprenorphine on unborn children.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
All females admitted to detox or receiving maintenance will receive education on MAT and pregnancy education.
All nursing staff will be re-trained with regard to proper procedure concerning this protocol.
Chart monitors will be perfomed monthly to ensure compliance.
Nurse Manage or Assistant Nurse Manager will train all nursing staff no later than October 1. 2018. |