INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on September 9-10, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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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 the review of personnel records, the facility failed to document that the facility director completed at least 12 clock hours of training annually.
The findings include:
Fourteen personnel records were reviewed on September 9-10, 2015. One personnel record was reviewed as the facility director and required the completion of 12 clock hours of annual training. The facility training year is from January 1 to December 31. The facility failed to document 12 clock hours of annual training in personnel record # 2.
Employee # 2 has been a facility director with the Pyramid Healthcare System since December 20, 2007 and transferred to this facility on February 10, 2014. Employee # 2 had only 7.5 training hours documented for the 2014 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will complete 12 clock hours of training annually. HR Coordinator will monitor compliance through documentation and proof of attendance in the personnel record. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of client records, the facility failed to document that verbal medication orders were put in writing and signed within the required timeframe by the prescribing physician in three of four client records.
The findings include:
Fifteen client records were reviewed on September 9-10, 2015. Four client records documented verbal orders. The facility did not document that verbal orders were signed within the required timeframe by the prescribing physician in client records # 4, 5 and 7.
Client # 4 was admitted into detox on March 21, 2015. A verbal order, dated 3/31/15, was signed by the prescribing physician. The verbal order was required to be signed by the prescribing physician within 24 hours. The date and time of the physician's signature was not documented.
Client # 5 was admitted into inpatient on August 13, 2015. A verbal order, dated 8/13/15, was signed by the prescribing physician. The verbal order was required to be signed by the prescribing physician within 3 business days. The date and time of the physician's signature was not documented.
Client # 7 was admitted into inpatient on July 27, 2015. A verbal order, dated 7/27/15, was signed by the prescribing physician. The verbal order was required to be signed by the prescribing physician within 3 business days. The date and time of the physician's signature was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning October 1, 2015, all verbal orders will be signed, dated and timed within the required timeframe by the prescribing physician. The Charge Nurses will monitor compliance through daily audits of charts. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to document that treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of three client records.
The findings include:
Fifteen client records were reviewed on September 9-10, 2015. Four client records were reviewed as outpatient records. Three records were reviewed for treatment and rehabilitation plan updates. The facility did not document that treatment and rehabilitation plan updates were completed at least every 60 days in client records # 9, 14 and 15.
Client # 9 was admitted on November 13, 2014. An individual treatment plan was completed on December 3, 2014. Treatment plan updates were completed on January 8 and February 21, 2015. Treatment plan updates due by 4/21, 6/21 and 8/21, 2015 were not documented.
Client # 14 was admitted on January 9, 2015 and discharged on June 17, 2015 . An individual treatment plan was completed on January 22, 2015. A treatment plan update was completed on March 26, 2015. A treatment plan update due by May 26, 2015 was not documented.
Client # 15 was admitted on November 25, 2014 and discharged on June 17, 2015. An individual treatment plan was completed on December 10, 2014. A treatment plan update was completed on February 4, 2015. Treatment plan updates due by 4/4 and 6/4, 2015 were not documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Outpatient Clinical Staff will be retrained by the Western Region Clinical Coordinator on the documentation and required time frames for completion of treatment and rehabilitation plans to ensure reviews and updates occur at least every 60 days. This retraining will be completed by October 15, 2015.
Client #9's missing treatment updates will be completed by October 30, 2015 by the individual counselor and completion will be ensured by the Western Region Clinical Coordinator.
Ongoing compliance with this standard will be insured through monthly chart monitors completed by the Clinical Supervisor beginning November 2015. |