INITIAL COMMENTS
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This report is a result of a licensure renewal inspection consisting of an onsite physical plant inspection completed on August 25, 2022, and offsite client record review conducted on September 2, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the inspections, 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 (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 the review of fourteen client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one record reviewed. Client #2 was admitted on July 25, 2022 and was still an active client at the time of the inspection. There was documentation that a call was made to the local pharmacy on August 4, 2022; however, there was no proper consent to release information form signed by the client prior to disclosure.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward all clients will complete release of information for collaborating pharmacy at initial medical appointment.
Compliance will be monitored monthly chart audits completed by nurse manager. Results of the open and closed chart monitors will then be submitted to the Program Director for further review. Any deficiencies noted will be address in supervision.
Counselors will monitor that all consents are current while clients are in treatment
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709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on a review of seven outpatient client records, the facility failed to document follow up information in one of three applicable client records. Client #12 was admitted on June 28, 2022 and was discharged on August 4, 2022. There was no documentation of follow up information being completed in the client record. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
A follow-up call within 7 days of discharge will be required for discharged patients. This follow-up call will be completed by the primary clinician and then documented with the electronic health record.
Compliance will be monitored monthly through open and closed chart reviews completed by the Regional Quality Manager and Clinical Supervisor. Results of the open and closed chart monitors will then be submitted to the Program Director for further review. Any deficiencies noted will be address in clinical supervision.
Director will ensure that clients who weren't called upon discharge, will be called and followed up on in real time and outcome of needs will be documented.
Director will be sending out discharge listings weekly and will require all counselors to ensure discharge call occurs upon official discharge.
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