INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7-8, 2018 at the Pyramid Healthcare-Quakertown facility by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Pyramid Healthcare-Quakertown 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to provide documentation of counseling experience or practicum for employee # 8.
Employee # 8 was hired on June 18, 2018 and was still employed at the time of the inspection. Employee was hired as a counselor without the required experience or a practicum requiring the employee to be hired as a counselor assistant for three months.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As this citation was reviewed with the Program Director upon exit interview, a plan of correction has already been implemented for this citation. Employee #8 has been reclassified as a Counselor Assistant as of 8/13/18. Program Director clarified with the Pyramid Regional Clinical Coordinator as well as Chief Clinical Officer the week of 8/13/18 as to the types of degrees and clinical experience employee #8 has, and in compliance with Regulation 704.7 (b), the employee will have weekly documented supervision with the clinical supervisor for 3 months. Upon completion of the weekly supervision for 3 months, the Program Director will again verify compliance of counselor assistant regulations with the Regional Clinical Coordinator and Chief Clinical Officer prior to promotion back to counselor for employee #8 |
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
The facility failed to ensure that employee's #9, #10, and #11 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training.
Employee # 9 was hired on October 21, 2014 and did not receive HIV/AIDS training until August 24, 2017.
Employee # 10 was hired on January 8, 2016 and had not received HIV/AIDS training at the time of the inspection. Training was due by January 8, 2018.
Employee # 11 was hired on April 7, 2016 and had not received HIV/AIDS training at the time of the inspection. Training was due by April 7, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to this inspection on 8/8/18, employee #11 was no longer employed with our facility effective 7/30/18. No plan of correction for this employee is needed.
Employee # 10 has been notified of his deficiency of training and the plan of correction implemented 9/13/18 is that the employee will attend HIV/AIDS training on 9/25/18.
Employee #9 attended the required training but past the required year timeframe, on 8/24/17. This was prior to the current Program Director's hire. The plan of correction for completing required trainings regarding 704.11 (c) (1) has been implemented by the Program Director on 9/13/2018. On 9/13/2018, the Program Director discussed citation with Human Resources Coordinator and was trained on the DDAP requirements in 704.11, and reviewed current system of communication between department supervisors and the Human Resources Coordinator. Implemented 9/13/2018, all communications regarding regulation 704.11 to individual department supervisors from the Human Resources Coordinator will be carbon copied for the Program Director to ensure compliance with 704.11 regulations and tasks and deadlines assigned by the HR Coordinator.
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705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
During a physical plant inspection, the silverware in the kitchen area was not covered and not in use.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The kitchen supervisor was onsite during the inspection and a plan of correction was implemented. Beginning 8/8/18, the kitchen supervisor notified all dietary staff that all silverware needs to be covered with plastic wrap when not in use, and compliance with 705.7 (b) (3) will be monitored by the kitchen supervisor on each shift worked. Regional Dietary Coordinator was notified of this citation on 8/8/18 as well and will check for compliance by all dietary staff at Quakertown during regular kitchen inspections. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to document a signed and dated annual evaluation with employee #3.
Employee #3 was hired on December 17, 2017 and was still in the position as of the date of the inspection. An annual review was conducted without a signature and date to establish when review was done.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure future compliance with 709.26 (b) (3) as the plan of correction, Program Director will review with all supervisors no later October 5, 2018 to be attentive when completing documentation with employees to ensure completed signatures and dates. |
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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 3, and 4.
Client # 1 was admitted on May 7, 2018 and was still an active client at the time of the inspection. Release of information to a probation officer on June 10, 2018 was within the established guidelines, however a release on June 1, 2018 to an individual with the same name but acknowledged as a family member, released information outside the 255.5 (b) guidelines.
Client # 3 was admitted on June 18, 2018 and was still an active client at the time of the inspection. A consent to release form was signed on June 15, 2018 to a funding source and department of public welfare, that allowed for the release of medication administration, history and physical, treatment progress, psychological evaluation, and physical assessment.
Client # 4 was admitted on July 11, 2018 and was still an active client at the time of the inspection. A consent to release form was signed on July 11, 2018 to a funding source that allowed for the release of medication administration, history and physical, treatment progress, psychological evaluation, and physical assessment.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In the cited clients' charts, effective 9/19/18, the Program Director noted the correct consent to use according to the proper confidentiality laws. The clinical site supervisor coordinated 9/19/18 with the Eastern Clinical Coordinator to schedule a mandatory in house training as the POC for all intake and clinical staff to review 709.28 (c ) regulations, including requirement pertaining to obtainment of informed and voluntary consent from each client; documentation of the date in which the staff and client signature was obtained; expiration date of the consent; the obtainment of specific information regarding the particular name, agency, or organization to which the disclosure would be made. Clinical Supervisor will conduct monthly chart audits to ensure compliance with regulation 709.28 (c ). |
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 document a signed consent to Buprenorphine treatment in client record # 5.
Client # 5 was admitted on January 11, 2018 and discharged on March 22, 2018. There was no documentation of a consent to treatment for Buprenorphine in the client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The site nurse manager is responsible for reviewing all necessary documentation after the complete assessment, within 24 hours, to ensure compliance. In lieu of a Nurse Manager, the Program Director and/or Regional Director of Nursing will complete weekly chart audits of all client receiving MAT at the facility.
This lack of consent occurred due to computer error with the signature pad for the client to sign. To remain compliant with 715.12 (1-5) in the future, the plan of correction to be implemented no later than October 8, 2018, the prescribing physician will have a paper copy available at the time of assessment, which will then be scanned into the chart, to ensure consent has been obtained and is appropriately documented.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to provide documentation that the clients received counseling services according to their individual comprehensive treatment plan in 4 of 7 charts reviewed.
Client # 1 was admitted on May 7, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan developed on May 7, 2018 indicated 5 individual sessions per week and one group session per week. The chart's record of service and progress notes indicated that the client did not receive an individual session until May 25, 2018 and did not receive five individual sessions weekly thereafter. The chart's record of service and progress notes indicate sessions on June 1, 8, 11, 12, 18, 21, 26, 29, July 3, 10, 18, 25, and 31.
Client # 4 was admitted on July 11, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan developed on July 13, 2018 indicated one individual session per week and five group sessions per week. The chart's record of service and progress notes indicated that the client did not receive an individual session the weeks of July 15-21, 228-28, and July 29- August 4.
Client # 6 was admitted on February 6, 2018 and was discharged on May 7, 2018. A comprehensive treatment plan developed on February 16, 2018 indicated one individual session per week and five group sessions per week. The chart's record of service and progress notes indicated that the client did not receive any group sessions after April 18, 2018.
Client # 7 was admitted on March 27, 2018 and was discharged on May 29, 2018. A comprehensive treatment plan developed on April 18, 2018 indicated one individual session per week and five group sessions per week. The chart's record of service and progress notes indicated that the client did not receive individual sessions the weeks of April 8-14, 22-28 and May 13-19.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/13/18, Program Director reviewed regulations with Clinical Supervisor. To increase compliance with 709.52 (c), Clinical Supervisor will re-train all clinical staff no later than 10/09/18, on treatment standards and requirements as they pertain to the frequency of individual and group therapy sessions. Clinical Supervisor will be responsible for monitoring continued compliance in this area through regular monthly chart audits |