INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 9, 2013, by staff from the Program Licensure Division. Based on the findings of the on-site licensing 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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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the review of patient records, the facility failed to maintain the confidentiality in one of one patient record reviewed.
The findings include:
Six patient records were reviewed on September 9, 2013. Patient # 3's individual patient controlled drug record had another patient's identifying information included on the form. The individual patient controlled drug record had a note documented on August 9, 2013. The form said "see note on back." The note on the back of patient # 3's individual patient controlled drug record included another patient's first and last name.
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Plan of Correction
All Hillside Staff that have access to medical records will be given the Policy and Procedures (PHC 3.6 Confidentiality: Substance Abuse Treatment and PHC 3.5 Confidentiality: General Standards regarding confidentiality and PHC 3.6 Confidentiality: Substance Abuse Treatment). Both of these Policies and Procedures comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). Reviewing these policies and procedures will ensure that all staff is aware that only information pertaining to the client should be kept in their chart, and all information not pertaining to the client needs to be removed. This will be completed by 10/1/2013. The Supervisor for each Department will be responsible for reviewing these policies and procedure with each of their staff. Each staff will need to sign off that they have received and understand the policies. The sign off sheet and evaluation form will be kept in the employee record. These Policy and Procedures will also be reviewed with each employee by their department supervisor at their 90 day evaluation period and reviewed annual. Proper documentation will be maintained in their file. New employees will be trained by the training personnel and/or their immediate supervisor during their orientation period regarding all policies and procedures related to confidentiality. The new employee will need to sign off indicating that they have received these policies and procedures.
To ensure that all active and inactive charts are in compliance with 4 Pa. Code 255.5 an audit of all charts will be conducted by 10/1/13. Only information pertaining to the individual client will be kept in their record, and any identifying information pertaining to another client shall be removed. To ensure that no further compliance issues will occur pertaining to 4 Pa. Code 255.5 each chart will be reviewed within 30 days of discharge, and any information not pertaining to the client would be removed. Active charts will be audited each month and all information not pertaining to the client will be removed. The clinical supervisor and nurse manager will be responsible for completing the chart audit and removing any information not pertaining to the client. The audit tool indicating that each chart had been reviewed will be maintained by the clinical supervisor and/or nursing manger.
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709.32(a) LICENSURE Medication Control
709.32. Medication control.
(a) Projects which furnish pharmaceutical services shall comply with all applicable Federal, State and local ordinances, statutes and regulations regarding the storing, compounding, administering or dispensing of medication.
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Observations
Based on a review of a patient record, the facility failed to comply with the proper administering and dispensing of medication for patient #3.
The findings include:
Based on a review of a patient's controlled drug record, the facility failed to comply with the storing, compounding, administering or dispensing of medication. According to patient # 3's record, the patient had been prescribed a Subutex. On the back of the individual patient controlled drug record, there was a note written that stated, "Buprenorphine 2 mg given to Patient "X" from patient #3's card, same dose, route, no medication error occurred."
This documentation showed that a medication error did occur, however, the facility failed to acknowledge it as being an error.
An interview with the nursing staff on duty confirmed the documentation that was recorded in this patient record.
Patient record # 2 contained a document for a controlled substance prescription (Class II-V). The form is used for pharmacy services and was a prescription for patient # 2 to received Subutex 2 mg SL every four hours for 24 hours, then 2 mg SL every 6 hours for 24 hours, then 2 mg every 8 hours for 24 hours and then 2 mg SL every 12 hours for 24 hours. This form was completed by someone other than the medical director. The form had the medical director's signature and DEA number on it, however, it was not an original signature. The signature and DEA number appeared to be a photocopy on the form.
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Plan of Correction
Medical Personnel were re-trained on Policies Procedures (PHC 2.14 Medication Errors and Adverse Drug Reactions) guidelines/protocols for medication errors and on completing medication error(s) notification, and documentation. The Nursing Manager was responsible for completing the training by 9/17/2013(with the exception of staff that was not working during this time period and they were trained the first day they returned to work) and each staff member signed a training evaluation indicating that they received the training. New medical employees will be trained by the Nursing Manger during their orientation period, at their 90 day and annually evaluation. All new Medical Personnel will provide a signature indicting that they have received and reviewed this information and evaluation form will be kept in the employee record.
All photocopies of controlled substance forms utilized for pharmacy acquisition of controlled substances were removed from the facility. Medical Personnel were re-trained that only original physician signature is allowed on all controlled medication order(s). The retraining of all the current Medical Personnel was completed by 9/17/2013(With the exception of staff that was not working during this time period and they were trained the first day they returned to work). The Nursing Manager was responsible for providing the training and each staff member signed an evaluation form that will be kept in their employee record. New medical personnel will be trained by the Nursing Manger during their orientation period, at their 90 day, and annually evaluation. All new Medical Personnel will provide a signature indicting that they have received and reviewed this information and evaluation form will be kept in the employee record.
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709.63(a)(4) LICENSURE Medication records
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(4) Medication records.
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Observations
Based on the review of patient records, the facility failed to have a complete patient record which included medication records.
The findings include:
Six patient records were reviewed. All records were reviewed for the patient's medication administration records (MAR). The facility failed to document accurate medication records in three of six records reviewed.
Patient # 2 had an order for Subutex 2 mg every 8 hours for 24 hours. The patient was to receive a dose at 1300 hours on August 6, 2013. The medication administration record documented the patient did not receive their dose at 1300 hours. There was no documentation as to why the patient did not receive the dose documented on the MAR.
Patient # 4's record was reviewed for the medication administration records for the administration of Subutex. The nursing progress notes documented the patient received Subutex at 2100 hours on 8/26/2013. The record failed to contain a medication administration record for Subutex.
Patient # 5's record included a Medication Administration Record that showed the patient was to received 2 mg of Subutex on August 18, 2013 at 0600 hours. The facility failed to document why the patient did not receive this medication dose.
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Plan of Correction
Medical staff was re-trained on Policy and Procedures (PHC 2.14 Medication Errors, PHC 2.11 Medication Use, and PHC 2.20 Medication Use: Short Term Buprenorphine Detoxification) regarding the dispensing of medication and the documentation of medication in the medication administration record (MAR). Also Medical Personnel were trained regarding documentation required if a client(s) did not receive his/her medication at the scheduled hour or if there was a Medication Error. The Nurse Manger completed this training for the medical personnel by 9/17/2013(With the exception of staff that was not working during this time period and they were trained the first day they returned to work) and each staff member signed a training form, which will be kept in their employee file. New medical employees will be trained by the Nursing Manger during their orientation period, at their 90 day and annually evaluation. All new Medical Personnel will sign an evaluation form indicated that they have received this training and will be kept in the employee record. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of the patient records, the facility failed to ensure that the patient was dosed following the completion of an initial drug-screen urinalysis.
The findings include:
Six patient records were reviewed on September 9, 2013. Five records required drug-screen urinalysis prior to the patient being dosed with Subutex. Four of five records failed to document that the narcotic treatment physician reviewed the urinalysis results prior to receiving their first dose.
Patient # 1 was admitted into treatment on August 30, 2013. Patient # 1 received a dose of of Subutex on September 1, 2013. The documented results of the urinalysis indicated that the report was received by the facility on September 4, 2013. There was no additional documentation that verified that the urinalysis results were reviewed prior to the administration of Subutex or that the doctor reviewed the results
Patient # 3 was admitted on July 29, 2013. Patient # 3 received their first dose of Subutex on July 30, 2013. There were no urinalysis results included in this patient record.
Patient # 4 was admitted on August 22, 2013. The nursing notes documented that the patient received their first dose of Subutex on August 26, 2013. The patient record failed to include a Medication Administration Record. The documented results of the urinalysis indicated that the report was received by the facility on August 29, 2013. There was no additional documentation that verified that the urinalysis results were reviewed prior to the administration of Subutex or that the doctor reviewed the results. Additionally, the urine test results did not show the patient being positive for opiates.
Patient # 5 was admitted on August 13, 2013. Patient # 5 received their first dose of Subutex on August 15, 2013. The documented results of the urinalysis indicated that the report was received by the facility on August 17, 2013. There was no additional documentation that verified that the urinalysis results were reviewed prior to the administration of Subutex or that the doctor reviewed the results
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Plan of Correction
Medical staff and medical director were re-trained on Policy and Procedure (PHC 2.20 Medication Use: Short Term Buprenorphine Detoxification) of requirements of subutex initiation and required urine drug testing results to be obtained and reviewed before subutex is initiated. The re-training of all the current Medical Personnel was completed by 9/17/2013 by the Nursing Manager (With the exception of staff that was not working during this time period and they were trained the first day they returned to work).
and each staff member signed a training form indicating that they received the training. This sign off sheet and evaluation form will be kept in the employee record. New medical employees will be trained by the Nursing Manger during their orientation period, at their 90 day, and annually evaluations. All new Medical Personnel will sign off sheet and evaluation form will be kept in the employee record.
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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on observation during the physical plant inspection, the facility failed to notify the Department of the change of authorized capacity.
The findings include:
The physical plant inspection took place on September 9, 2013 and the facility beds were counted. The facility was licensed for 20 non-hospital detoxification beds and 40 inpatient non-hospital drug-free beds. The facility had 20 non-hospital detoxification beds and 35 non-hospital drug-free beds. The facility failed to have the required number of licensed non-hospital beds. The facility was short 5 non-hospital drug free beds.
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Plan of Correction
In keeping in compliance with our current Department of Health License for 40 residential beds, we will ensure that all beds will be established and ready for clients. Here is a list of our current residential rooms that have beds setup ready for client use. In order to ensure that we keep incompliance with our license for 40 residential beds and 20 detoxification bed a procedure will be but in place by 10/2/2013. The procedure will include a survey of safety issues of each bedroom with in the facility. The onsite Risk Manger staff member will be required to maintain a weekly log indicating that he has inspected each bed room. The check list will included the correct number of beds within the room; ensure the beds are functional and ready for client use, safety issues will be noted. Safely issues will be communicated to the maintenance supervisor and program director. The onsite risk manger will review his findings in weekly team meetings and maintain an ongoing record of the surveys. The Program Manger will be responsible for ensuring that all maintenance issues are addressed and the facility complies with their license of having 40 rehabilitation beads and 20 detoxification beds.
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106 1
107 2
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110 2
112 2
202 2
203 2
204 2
205 2
207 2
208 2
209 2
210 2
211 1
212 2
213 2
214 2
215 2
216 2
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