INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 28, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facilities staff schedule work hours and the Fist Aid and CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR and First Aid during the project's hours of operation.
The CPR and First Aid certification cards were reviewed on November 28, 2017. The facility's hours of operation are: Monday through Thursday 6:30 am - 8:30 pm, and Friday 8:30 am - 3:30 pm. There were only two staff members that had documented current CPR certification on varied shifts.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Two staff members completed the CPR required training on 12/14/2017. All staff members currently trained are able to cover all hours of operation.
The remaining four staff members will receive their CRP training on January 24, 2018. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant tour during the licesning renewal inspection, the facility failed to ensure that the hot water temperature did not exceed 120 physical plant inspection took place on November 28, 2017 at approximately 11:50 am.
The hot water temperature was tested in the client bathroom and it read 125.7
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
Building Maintenance came to the Pyramid facility on 11/29/17 to adjust the water temperature to 120 degrees. They returned on 12/19/17 to check on water temperature for any fluxuation in temperature. Pyramid's Maintenance team has been notified and come out on 12/29/2017 to complete a follow up inspections on the water. Pyramid Maintenance ensured 120 degree temperature was accurate. Inspections will be conducted on water temperature for all water sources on a regular basis from Pyramid Maintenance. |
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
Based on a review of client records on November 28, 2017, the facility failed to obtain an informed and voluntary consent in two of six client records.
Client #2 was admitted to treatment on December 8, 2016 and discharged on March 29, 2017. The facility failed to document a release in the client record for an emergency contact, as required.
Client #4 was admitted to treatment on July 21, 2017 and is still an active client. The facility failed to document a release in the client record for the funding source or an emergency contact, as required.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during theDecember 21, 2016 inspection.
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Plan of Correction
Program director created an appointment checklist for Assessments and Intakes for all counselors to follow when completing appointments. Checklist was put into place on 12/4/2017. All staff participated in a training on 12/4/2017 to learn the checklists and implement processes.
Program director created list of all required documents for Lead Counselor who is checking and sign off on assessments. Lead Counselor will use checklist as an audit process when signing off on assessments to ensure all consents for family, funding and consent to treatment are completed within the assessment appointment. Checklist was put into place on 12/4/2017
PD will continue monthly chart audits on each counselor to double check that consents are completed in given time frames and correctly by all staff. Program director will continue to complete these audits on a monthly basis.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on the review of client records on November 28, 2017, the facility failed to obtain an informed, voluntary, written consent before an agent was administered for maintenance in one of form client records.
Client #3 was admitted to treatment on September 3, 2017 and is still an active client. The client was prescribed 4/1 mg of Suboxone on October 16, 2017. There was no documentation of an informed consent in the client record at the time of the inspection.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
Program Director and Nursing Director created a Medication Assisted Treatment appointment audit form for nursing staff to follow when completing appointments. Consents, including the informed consent are listed on this guide. Guide was created on 11/16/17 but not put into effect until 11/29/17 after review from clinical and medical teams.
Nursing staff and Director of nursing staff will be conducting monthly chart audits on closed and open charts enrolled in the Medication Assisted Treatment program. Nurse will use to audit process to ensure she is gaining all consents and documentation in appropriate time frames. Audits will be conducted every 15th of every month.
Program Director and Nursing staff participated in a call to discuss the chart audit process and changes on 12/21/2017.
Program Director will conduct chart audits on medication assisted treatment clients enrolled in the program. Audits will be conducted quarterly.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on November 28, 2017, the facility failed to complete psychosocial evaluations in three of six client records.
Client #3 was admitted to treatment on September 3, 2017 and was still an active client.. The facility failed to document a psychosocial evalustion in the client record at the time of the inspection.
Client #4 was admitted to treatment on July 21, 2017 and was still an active client. The facility failed to document a psychosocial evalustion in the client record at the time of the inspection.
Client #5 was admitted to treatment on August 1, 2017 and discharged on September 19, 2017. The facility failed to document a psychosocial evalustion in the client record at the time of the inspection
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director created appointment checklist for Intake/ Treatment planning appointments which include the completion of Psychosocial evaluations on the list within 3 day time frame of Treatment plan. Checklist was put into place on 12/4/17 for counselors to use as reference. All staff participated in a training on 12/4/2017 to learn the checklists and implement processes.
Program director will audit charts when signing off on treatment plans to ensure completion of psychosocial evaluations are completed in the appropriate time frames. Treatment plan reviews are completed on a weekly basis.
Program director will complete chart audits on each counselor to ensure that Psychosocial evaluations are completed in given time frames and correctly. Chart audits are completed monthly on all staff.
Client 3 -Psycho Social Evaluation was completed on 12/3/17.
Client 4- Psycho Social Evaluation was completed on 1/8/2018
Client 5 - Psycho Social Evaluation was completed on 7/27/17 at assessment but Psycho social evaluation was not present in the chart at time of the inspection. It is currently in the chart of client.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records on November 28, 2017, the facility failed to document a treatment plan update at least every 60 days in six of six client records reviewed.
Client #1 was admitted on March 6, 2017 and discharged on July 4, 2017. A comprehensive treatment plan was completed on March 8, 2017 and the client received one updated treatment plan on April 17, 2017 prior to discharge.
Client #2 was admitted on December 8, 2016 and discharged on March 29, 2017. A comprehensive treatment plan was completed on December 12, 2016 and the client received one updated treatment plan on January 9, 2017 prior to discharge.
Client #3 was admitted on September 3, 2017 and is still an active client. A comprehensive treatment plan was completed on September 5, 2017 and the client did not receive an updated treatment plan at the time of the inspection.
Client #4 was admitted on August 21, 2017 and is still an active client. A comprehensive treatment plan was completed on August 21, 2017. The updated treatment plan was due September 21, 2017. There was one updated treatment plan dated October 5, 2017 in the client record.
Client #5 was admitted on July 27, 2017 and discharged October 16, 2017. A comprehensive treatment plan was completed August 1, 2017 and the client did not receive an updated treatment plan prior to discharge.
Client #6 was admitted October 4, 2017 and is still an active client. A comprehensive treatment plan was completed October 10, 2017 and the client did not receive an updated treatment plan prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director created appointment checklist for Intake/ treatment Plan appointments as well as update appointments that require staff to check when last treatment planning appointment was completed and update at individual sessions. Checklist was put into place on 12/4/2017 for counselors to use as reference. All staff participated in a training on 12/4/2017 to learn the checklists and implement processes.
In addition to the check list, staff will be utilizing the task function in the electronic chart system that will remind counselors of when the treatment plan update for each client will be due. The task will alert them that treatment plans are due and counselor can ensure they have an individual scheduled with the client. Task function was put into place on 12/4/17.
Program director will conduct chart audits on each counselor to ensure that treatment plan updates are completed in given time frames and correctly. Chart audits are completed monthly on all staff.
Client 3- active client at time of inspection- treatment plan update was completed on 11/28/17. Since then client has been discharged.
Client 4- active client at time of inspection- treatment plan update was completed on 12/7. Client is still active.
Client 6 - active client at time of inspection - treatment plan was not updated due to client completing treatment on day after inspection. Discharge planning and paperwork were completed.
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