INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and a Buprenorphine monitoring inspection conducted on August 13, 2019 until August 15, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Pyramid Healthcare Inc.-Duncansville 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records and supervision notes, it was discovered that that Employee # 20, whom was hired as a counselor assistant on May 13, 2019, was not under the close supervision of a trained counselor or clinical supervisor for the first 6-months of employment. There were no supervision notes for this employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility is unable to correct the deficiency at this time due to Employee #20 no longer being employed by Pyramid Healthcare.
Steps to be Taken to ensure on going compliance:
1.The Director of Clinical Services will retrain all Clinical Supervisors with regard to the close supervision required of a Counselor Assistant by a Clinical Supervisor for the first 6-months of employment.
Training will completed no later than November 1, 2019.
Steps to Ensure this deficiency does not recur:
1. The Director of Clinical Services will conduct monthly audits no later than the 30th of every month to ensure Clinical Supervisor's Supervision notes for all Counselor Assistants under their supervision are accurate,timely and complete.
Facility will be in compliance no later than November 1, 2019. |
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
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #18 received the minimum of 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #18 was hired as an Administrative Assistant on March 27, 2017 and promoted to a Counselor Assistant on February 10, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will correct the deficiency by scheduling Employee #18 to attend TB/STD and other health related topics within the next 90 days. This employee will be fully trained in the above subject no later than December 1, 2019.
All Supervisors will be retrained with regard to sending all employees to the TB/STD and other health related topics within the regulatory timeframe.
Supervisory Training will be completed no later than November 1,2019. Agenda and signature of attendance will serve as proof of compliance.
The Clinical Director will complete bi-annual audits of all clinical personnel to ensure compliance.
HR will complete audits to ensure compliance of non-clinical personnel as well. |
709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
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Observations
During a Project Wide review of the Policy and Procedures, the project failed to include sex and marital status in the Client Rights policy.709.30 (2), and also the project failed to include documentation of the reasons for removing sections from the record. 709.30 (3).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual will be updated by the Policy and procedure committee to include sex and marital status in section 709.30.
Chief Compliance Officer will ensure completion of policy by Sept 1, 2019.
The program director will be responsible to ensure that the new policy is shared with all staff by Sept 15, 2019. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During a review of client records on August 13th -15th, 2019, the facility failed to notify clients of all their civil rights in twenty-one out of twenty-one records.
Client #1 was admitted on June 11, 2019 and was current at the time of the inspection. Client #1 was not notified that the project may not discriminate on the basis of sex and color.
Client #2 was admitted on August 11, 2019 and was current at the time of the inspection. Client #2 was not notified that the project may not discriminate on the basis of sex and color.
Client #3 was admitted on August 10, 2019 and was current at the time of the inspection. Client #3 was not notified that the project may not discriminate on the basis of sex and color.
Client #4 was admitted on August 8, 2019 and was discharged on August 13, 2019. Client #4 was not notified that the project may not discriminate on the basis of sex and color.
Client #5 was admitted on January 3, 2019 and was discharged on January 7, 2019. Client #5 was not notified that the project may not discriminate on the basis of sex and color.
Client #6 was admitted on June 23, 2019 and was discharged on June 27, 2019. Client #6 was not notified that the project may not discriminate on the basis of sex and color.
Client #7 was admitted on March 16, 2019 and was discharged on March 21, 2019. Client #7 was not notified that the project may not discriminate on the basis of sex and color.
Client #8 was admitted on May 29, 2019 and was current at the time of the inspection. Client #8 was not notified that the project may not discriminate on the basis of sex and color.
Client #9 was admitted on June 20, 2019 and was current at the time of the inspection. Client #9 was not notified that the project may not discriminate on the basis of sex and color.
Client #10 was admitted on June 4, 2019 and was current at the time of the inspection. Client #10 was not notified that the project may not discriminate on the basis of sex and color.
Client #11 was admitted on January 31, 2019 and was discharged on April 1, 2019. Client #11 was not notified that the project may not discriminate on the basis of sex and color.
Client #12 was admitted on April 10, 2019 and was discharged on June 11, 2019. Client #12 was not notified that the project may not discriminate on the basis of sex and color.
Client #13 was admitted on November 5, 2018 and was discharged on January 4, 2019. Client #13 was not notified that the project may not discriminate on the basis of sex and color.
Client #14 was admitted on November 27, 2018 and was discharged on January 30, 2019. Client #14 was not notified that the project may not discriminate on the basis of sex and color.
Client #15 was admitted on July 31, 2019 and was current at the time of the inspection. Client #15 was not notified that the project may not discriminate on the basis of sex and color.
Client #16 was admitted on July 24, 2019 and was current at the time of the inspection. Client #16 was not notified that the project may not discriminate on the basis of sex and color.
Client #17 was admitted on July 24, 2019 and was current at the time of the inspection. Client #17 was not notified that the project may not discriminate on the basis of sex and color.
Client #18 was admitted on October 25, 2018 and was discharged on February 6, 2019. Client #18 was not notified that the project may not discriminate on the basis of sex and color.
Client #19 was admitted on May 9,2019 and was discharged on June 7, 2019. Client #12 was not notified that the project may not discriminate on the basis of sex and color.
Client #20 was admitted on March 18, 2019 and was discharged on January 4, 2019. Client #20 was not notified that the project may not discriminate on the basis of sex and color.
Client #21 was admitted on December 12, 2018 and was discharged on January 4, 2019. Client #21 was not notified that the project may not discriminate on the basis of sex and color.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information.
The new form to be added to Carelogic for all programs by September 1, 2019.
Program Director will ensure all staff are educated on the new form by September 15, 2019. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a review of the facilities incident reports on August 13, 2019- August 15, 2019, the facility documented eleven incidents that required the presence of police, fire or ambulance personnel, however they were not reported to the Department within three business days.
The incidents occurred on the following dates: August 31, 2018, November 2, 2018, October 14, 2018, October 19, 2018, November 19, 2018, December 6, 2018, December 10, 2018, two incidents on December 19, 2018, December 29, 2018, and December 31, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services and the Director of Nursing will retrain staff with regard to reporting the presence of police, fire or ambulance personnel within 3 business days of the incident.
Training by the Director of Clinical Services and Director of Nursing will be completed no later than November 1, 2019.
Chart monitors will be performed monthly to ensure compliance.
The facility will be in full compliance no later than November 1, 2019. |
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 obtain informed, voluntary, written consent before administering an agent to the patient for detoxification treatment.
Client #4 was admitted on August 10, 2019 and was discharged on August 13, 2019. There was no documentation of informed, voluntary, written consent at the time of inspection for detoxification treatment using Buprenorphine for Client #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Nursing will retrain staff with regard to documenting informed, voluntary, written consent at the time of induction for detoxification treatment using Buprenorphine.
Training conducted by the Director of Nursing will take place no later than November 1, 2019.
Monthly Chart monitors will be performed to ensure compliance. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
The facility failed to have laboratory test results ordered by the narcotic treatment program in one patient file.
Client #6 was admitted on June 23, 2019 and was discharged on June 27, 2019 from medical assisted detoxification. There was no documentation of laboratory test results ordered by the narcotic treatment program during the licensing inspection for Client #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately all admitted clients will be ordered laboratory tests. The Nursing Secretary Supervisor will retrain all staff with regard to ordering laboratory tests upon admission.
Documentation of testing requests and results will be documented or other special examinations given by the narcotic treatment program will be documented as well.
Daily chart audits will be completed by the Supervisor of Nursing Secretaries to ensure that all clients admitted the previous day have had laboratory testing ordered. If there is a finding that a laboratory test was not ordered, it will be ordered immediately.
The Director of Nursing will retrain all staff with regard to ordering laboratory tests upon admission of all clients, as well as documenting the results of laboratory tests or other special examinations given by the narcotic treatment program.
The Director of Nursing will complete retraining of staff no later than November 1, 2019.
Confirmation of training will be exemplified by sign in sheets and agenda reflecting said training.
The Director of Nursing will conduct monthly chart audits of the ordering of laboratory testing of all admitted clients no later than the 30th of each month.
Said monitor findings will be documented. Any monitor finding falling below 85% will result in a plan of correction to be completed by the staff responsible. Director of Nursing will assure compliance with POC through signing off on POC completed.
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