INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a Buprenorphine monitoring inspection conducted on October 8, 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. 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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709.30 (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 the review of client records during an on-site renewal inspection on October 8, 2019, it was determined that the project failed to notify seven out of seven clients that the project may not discriminate in the provision of services on the basis of color and sex.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the Client's Rights form in Carelogic to include the missing information. The new form will be added to Carelogic for all programs by November 4, 2019. Executive Director will ensure all staff are educated on the new form by November 11, 2019. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
During the review of client records during an on-site renewal inspection on October 8, 2019, it was determined that the project failed to notify seven out of seven clients that they have the right to appeal a decision limiting access to their records to the director.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CareLogic forms team will revise the Consent to Treat form to include all of the necessary language regarding an individual's right to review their records. The revision will be posted live in the EMR on November 4, 2019. Executive Director will review the information with staff by November 10, 2019. |