Observations
Based on a review of fire drill logs from September 12, 2024 through June 30, 2025 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There was no documentation, a fire drill was conducted during sleeping hours.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Driector reviewed this with the maintenance team and risk team during our monthly meeting on 8/1/25. Staff were retrained on fire drill protocol and proper documentation. Executive Director reviewed policy on documenting drills every 6 months during sleep hours. We reviewed sleep hours, to ensure they are not occurring during MAT med pass times. Executive Director and Safety Leader will monitor monthly fire drills for compliance and will address any ongoing areas of concern. |
Observations
Based on the review of client records, the project failed to offer a copy of release of information forms for the funding source in seven of seven client records reviewed.
Client #1 was admitted on February 12, 2025 and was still active at the time of the inspection. There was no documentation that a copy of the informed and voluntary consent to release information form for a funding source dated February 12, 2025, was offered to the client.
Client #2 was admitted on February 27, 2025 and was still active at the time of the inspection. There was no documentation that a copy of the informed and voluntary consent to release information form to a funding source dated February 25, 2025, was offered to the client.
Client #3 was admitted on February 28, 2025 and was still active at the time of the inspection. There was no documentation that a copy of the informed and voluntary consent to release information form to a funding source dated February 27, 2025, was offered to the client.
Client #4 was admitted on September 25, 2024 and discharged on October 29, 2024. There was no documentation that a copy of the informed and voluntary consent to release information form to a funding source dated September 24, 2024, was offered to the client.
Client #5 was admitted on August 30, 2024 and discharged on October 16, 2024. There was no documentation that a copy of the informed and voluntary consent to release information form dated August 29, 2024, was offered to the client.
Client #6 was admitted on September 23, 2024 and discharged on February 25, 2025. There was no documentation that a copy of the informed and voluntary consent to release information form dated September 22, 2024, was offered to the client.
Client #7 was admitted on September 26, 2024 and discharged on March 17, 2025. There was no documentation that a copy of the informed and voluntary consent to release information form dated September 25, 2024, was offered to the client.
These findings were reviewed with 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, Clinical Supervisor will be responsible for ensuring completion of the Consent for Treatment, Payment and Healthcare Operations consent with those clients and offering a copy.
Executive Director and Clinical Sueprvisor 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 our clinical meeting on 8/11/25. This re-education will be recorded in the meeting minutes/notes.
In order to monitor compliance with our plan of correction, the Clinical Supervisor will be responsible for weekly supervision with direct care staff to ensure compliance. Executive Director will supervise the Clinical Supervisor weekly to monitor the plan of correction. Executive Director will provide updates to the Regional Director bi-weekly to ensure compliance with plan of correction. |