Observations
Based on a review of the facility ' s written plan for the coordination of client treatment and rehabilitation services which includes but is not limited to the written procedures for the management of treatment/rehabilitation services for clients, the facility failed to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against medical advice in three out of nine applicable records reviewed.
Client #3 was admitted to the detoxification level of care on December 3, 2024, and left against medical advice on December 6, 2024. There was no documentation that the emergency contact was notified.
Client #5 was admitted to the detoxification level of care on August 31, 2024 and left against medical advice on September 3, 2024. There was no documentation that the emergency contact was notified.
Client #12 was admitted to the non-hospital residential level of care on August 30, 2024 and left against medical advice on September 4, 2024. There was no documentation that the emergency contact was notified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All applicable staff will receive a re-training regarding communications with Emergency Contacts following all forms of non-routine discharges by no later than 7/31/2025. Supervisory staff will routinely complete audits of client charts for any clients who are discharged with a non-routine status, ensuring compliance with emergency contact notifications. Leadership will review the results of these audits upon completion. |
Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in seventeen out of seventeen client records reviewed.
Client #1 was admitted to the detoxification level of care on June 17, 2025 and was discharged on June 23, 2025. There was no documentation that a copy of the informed and voluntary consent to release information form for a funding source dated June 17, 2025, was offered to the client.
Client #2 was admitted to the detoxification level of care on October 25, 2024 and discharged on October 31, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated October 25, 2024, were offered to the client.
Client #3 was admitted to the detoxification level of care on December 3, 2024 and discharged on December 6, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated December 3, 2024, was offered to the client.
Client #4 was admitted to the detoxification level of care on August 30, 2024 and discharged on September 4, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated August 30, 2024, was offered to the client.
Client #5 was admitted to the detoxification level of care on August 31, 2024 and discharged on September 3, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated August 31, 2024, was offered to the client.
Client #6 was admitted to the detoxification level of care on March 4, 2025 and discharged on March 5, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated March 4, 2025, was offered to the client.
Client #7 was admitted to the detoxification level of care on March 7, 2025 and discharged on March 8, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated March 7, 2025, was offered to the client.
Client #8 was admitted to the detoxification level of care on June 20, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated June 20, 2025, was offered to the client.
Client #9 was admitted to the detoxification level of care on June 18, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated June 18, 2025, was offered to the client.
Client #10 was admitted to the detoxification level of care on June 14, 2025 and was s till active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated June 14, 2025, was offered to the client.
Client #11 was admitted to the non-hospital residential level of care on June 21, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated June 21, 2025, was offered to the client.
Client #12 was admitted to the non-hospital residential level of care on August 30, 2024 and discharged on September 4, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated August 30, 2024, was offered to the client.
Client #13 was admitted to the non-hospital residential level of care on March 10, 2025 and discharged on March 19, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated March 10, 2025, was offered to the client.
Client #14 was admitted to the non-hospital residential level of care on April 21, 2025 and discharged on April 25, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated April 21, 2025, was offered to the client.
Client #15 was admitted to the non-hospital residential level of care on May 7, 2025 and discharged on May 12, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated May 7, 2025, was offered to the client.
Client #16 was admitted to the non-hospital residential level of care on April 16, 2025 and still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated April 16, 2025, was offered to the client.
Client #17 was admitted to the non-hospital residential level of care on May 14, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated May 14, 2025, was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Pyramid Healthcare has submitted a ticket into its health records system to add an enhancement. This enhancement will denote that a copy of the Consent for Treatment, Payment and Healthcare Operations consent is offered to the client and will be memorialized and maintained in the client record. This denote will be a required field at the bottom of the document. As a result, staff will be unable to move forward to complete the document without the review and acknowledgement of whether a copy was offered to the client or not. Compliance monitors on a monthly basis the completion of the Consent for Treatment, Payment and Healthcare Operations consent for all clients active in treatment. The monitoring information is shared with the facilities operations and clinical leadership team through a scorecard to review and identify if any client receiving care may be missing one. If clients are determined to be missing a document, facility leadership and/or designee will be responsible for ensuring completion of the Consent for Treatment, Payment and Healthcare Operations consent with those clients and offering a copy. Until this change is able to made in the electronic record system, staff will utilize a memo to chart to indicate that a copy was offered to the client. Director of Intake and or designated staff will complete on-going randomized chart audits to ensure 100% compliance with this expectation.
Additionally, facility leadership will re-educate staff on the expectation to offer a copy of the Treatment, Payment and Healthcare Operations consent to each client and document that offering on the updated consent form in a department meeting by 8/30/25. This re-education will be recorded in the meeting minutes/notes or individual supervision notes if staff is not present for the department meeting.
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