INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25-26, 2017 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
A physical plant inspection was conducted on October 26, 2017. On the 2nd floor male residential unit, a bathroom door in bedroom # 216 was observed to be damaged with large holes.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The current doors are particle board doors that break easily.
New, wooden doors are ordered for the entire facility. 20 doors are ordered at a time and replaced, and then a new order of doors is put in. The doors for this particular unit have been ordered but are on back order. Immediately upon receiving doors, they will be replaced. Once all doors within the facility are replaced, extra doors will be kept on hand to immediately replace any further damage that may occur.
Facility will be in full compliance with all doors replaced within the facility by 1-15-18, and at that time and extra 20 doors will be kept on site to be able to make repairs as they are necessary. Maintenance supervisor, will monitor doors monthly to ensure they are up to compliance and if they are not he will appoint a member of maintenance to replace the doors. Head of Maintenance for the Western Region will continue to check with maintenance supervisor monthly to ensure doors are in compliance.
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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
Seven client records were reviewed on October 25-26, 2017. The facility failed to obtain an informed and voluntary consent to release information that did not exceed the limitations imposed in 4 Pa. Code 255.5 (b) for client records # 1, 2, and 5.
Client # 1 was admitted into inpatient detoxification treatment on 10/20/17 and was discharged on 10/25/17. A consent to release information to a medical assistance provider, signed and dated by the client on 10/20/17, authorized the release of the following information: discharge summary/aftercare plan and medication administration records.
Client # 2 was admitted into inpatient detoxification treatment on 10/20/17 and was still active in treatment. A consent to release information to a medical assistance provider, signed and dated by the client on 10/20/17, authorized the release of the following information: discharge summary/aftercare plan and medication admistration records.
Client # 5 was admitted into inpatient rehabilitation treatment on 10/6/17 and was still active in treatment. A consent to release information to a medical assistance provider, signed and dated by the client on 10/6/17, authorized the release of the following information: discharge summary/aftercare plan and psychiatric evaluation.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 11-1-17 Clinical Director will train clinical staff and intake staff on valid consents to ensure valid consents are being completed. Clinical Director and Clinical Supervisors will monitor charts monthly to ensure consents are completed accurately by staff. If there are any problem consents, those staff filling out the consents will be re trained until the consents are correct.
Records 2 and 5 ended up leaving prior to being able to complete a correct release of information. Moving forward, Clinical Director will check charts weekly, in addition to the monthly chart audits, to ensure that any incorrect ROI's are filled out correctly.
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709.62(c)(4) LICENSURE Consent to TX
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(4) Consent to treatment.
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Observations
Four client records were reviewed for the inpatient detoxification activity on October 25-26, 2017. The facility failed to document a written consent to treatment for client record # 4.
Client # 4 was admitted into inpatient detoxification treatment on 9/9/17 and was then transferred to inpatient rehabilitation treatment on 9/14/17. A written consent to inpatient detoxification treatment was not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 11-1-17, Intake coordinator will develop a check list that includes all intake documentation needing to be completed, including the consent to treatment. Intake coordinator will teach intake staff along with nursing staff about this checklist no later than 11-17-17. Nursing staff will be responsible to complete intake paperwork, including consent to treatment and ROI's, along with their nursing documentation for after hour's admissions. Starting 11-1-17, Nursing secretary will monitor charts for review purposes daily to ensure accurate documentation was conducted in each chart including consent to treatment and proper ROI's. If something was missed, it will be rectified during that shift to ensure documentation will no longer be missing. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Four client records were reviewed for the inpatient detoxification activity on October 25-26, 2017. The facility failed to document a complete psychosocial evaluation for client records # 1, 2, and 3.
Client # 1 was admitted into inpatient detoxification treatment on 10/20/17 and was discharged on 10/25/17. A Biopsychosocial assessment was completed for the client on 10/20/17. A complete psychosocial evaluation was not documented in the client's record.
Client # 2 was admitted inpatient detoxification treatment on 10/20/17 and was still active in treatment. A Biopsychosocial assessment was completed for the client on 10/20/17. A complete psychosocial evaluation was not documented in the client's record.
Client # 3 was admitted into inpatient detoxification treatment on 8/31/17 and was then transferred to inpatient rehabilitation treatment on 9/8/17. A Biopsychosocial assessment was completed for the client on 8/31/17. A complete psychosocial evaluation was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Intake Supervisor will re train assessors, and any staff on completing accurate and detailed Intake Assessments. Training will occur by 11-10-17. Staff will do a full assessment in the summary section and include all information that would be needed for a psychosocial evaluation. Intake Supervisor will monitor assessments weekly and review with assessors what improvements need to be made. |
709.63(a)(2) LICENSURE D & A support plan
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:
(2) Drug and alcohol support plan.
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Observations
Four client records were reviewed for the inpatient detoxification activity on October 25-26, 2017. The facility failed to document a drug and alcohol support plan for client records # 1, 2, and 4.
Client # 1 was admitted into inpatient detoxification treatment on 10/20/17 and was discharged on 10/25/17.
Client # 2 was admitted into inpatient detoxification treatment on 10/20/17 and was still active in treatment.
Client # 4 was admitted into inpatient detoxification treatment on 9/9/17 and was then transferred to inpatient rehabilitation treatment on 9/14/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 11-1-17 all nursing staff will complete Detox Treatment Plan on all clients within the detox unit. This document was reviewed with all staff and Detox nurse manager will complete chart audits weekly to ensure documentation is getting done. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Six client records were reviewed for the use of Buprenorphine in the inpatient detoxification and inpatient rehabilitation activities on October 25-26, 2017. The facility failed to document the countersignature of either the medical director or a narcotic treatment physician on records pertaining to functions performed by the certified registered nurse practitioner for client records # 2, 3, 4, and 5.
Client # 2 was admitted into inpatient detoxification treatment on 10/20/17 and was still active in treatment. The client's record contained documentation of a physical examination conducted by the certified registered nurse practitioner on 10/21/17. The physical examination record was not countersigned by the physician.
Client # 3 was admitted into inpatient detoxification treatment on 8/31/17 and was then transferred into inpatient rehabilitation treatment on 9/8/17. The client's record contained documentation of a physical examination conducted by the certified registered nurse practitioner on 9/1/17. The physical examination record was not countersigned by the physician.
Client # 4 was admitted into inpatient detoxification treatment on 9/9/17 and was then transferred into inpatient rehabilitation treatment on 9/14/17. The client's record contained documentation of a physical examination conducted by the certified registered nurse practitioner on 9/12/17. The physical examination record was not countersigned by the physician. The certified registered nurse practitioner also conducted the determination of addiction for the client on 9/11/17 and documentation of this function was not countersigned by the physician.
Client # 5 was admitted into inpatient rehabilitation treatment on 10/6/17 and was still active in treatment. The client's record contained documentation of a physical examination conducted by the certified registered nurse practitioner on 10/6/17. The physical examination record was not signed by the certified registered nurse practitioner, and was not countersigned by the physician.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning 11-15-17, all documentation completed by a CRNP will be counter signed by a physician or MD. Nurse managers will review documentation monthly during chart audits to ensure this is being completed.
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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
Six client records were reviewed for the use of Buprenorphine in the inpatient detoxification and inpatient rehabilitation activities on October 25-26, 2017. The facility failed to obtain an informed written patient consent prior to the administration of Buprenorphine for client records # 1, 2, 3, 4, 5, and 6.
Client # 1 was admitted into inpatient detoxification treatment on 10/20/17 and was discharged on 10/25/17. The client received an initial dose of Subutex on 10/21/17.
Client # 2 was admitted into inpatient detoxification treatment on 10/20/17 and was still active in treatment. The client received an initial dose of Subutex on 10/22/17.
Client # 3 was admitted into inpatient detoxification treatment on 8/31/17 and was discharged on 9/8/17. The client received an initial dose of Subutex on 9/1/17.
Client # 4 was admitted into inpatient detoxification treatment on 9/9/17 and was then transferred to inpatient rehabilitation treatment on 9/14/17. The client received an initial dose of Subutex on 9/11/17.
Client # 5 was admitted into inpatient rehabilitation treatment on 10/6/17 and was still active in treatment. The client received an initial dose of Subutex on 10/25/17.
Client # 6 was admitted into inpatient rehabilitation treatment on 7/17/17 and was discharged on 9/12/17. The client received an initial dose of Suboxone on 8/5/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 10-26-17, MAT consents are placed within the chart and signed upon intake. Any client coming in to treatment will sign the consent reviewing the risks of suboxone, methadone, etc. Pregnant females will also sign this consent upon entering treatment. Effective 10-26-17, this consent was reviewed with intake staff, so they can complete it with the clients, and have an understanding if the consent to explain it to the clients. Monthly chart audits by Detox nurse manager will ensure this is being completed.
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709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Three client records were reviewed for the inpatient rehabilitation activity on October 25-26, 2017. The facility failed to document a written consent to treatment for client record # 6.
Client # 6 was admitted into inpatient rehabilitation treatment on 7/17/17 and was discharged on 9/12/17. A written consent to treatment was not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 11-1-17, Intake coordinator will develop a check list that includes all intake documentation needing to be completed including the consent to treatment. Intake coordinator will teach intake staff along with nursing staff about this checklist no later than 11-17-17. Nursing staff will be responsible to complete intake paperwork including consent to treatment along with their nursing assessments, for after hour's admissions. Starting 11-1-17, Nursing secretary will monitor charts for review purposes daily to ensure accurate documentation was conducted in each chart including consent to treatment. If something was missed, it will be rectified during that shift to ensure documentation will no longer be missing. |