INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 1-16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection, the facility failed to maintain furnishings in a state of good repair.In room G18 there was a chair with tears and a loveseat in the men ' s south community room that was torn.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The furniture has been replaced. Inspection of furniture will be included into our monthly facility plant inspection(and submitted through the Pyramid intranet page under the safety and Environment) to ensure all furnishings are in a state of good repair. Any furnishings present that are not in a state of good repair will be replaced |
705.5 (h) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(h) Each bedroom shall be ventilated by operable windows or have mechanical ventilation.
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Observations
Based on a physical plant inspection, the facility failed to ensure each bedroom was ventilated by operable windows or have mechanical ventilation. The windows in all of the bedrooms were sealed shut for the winter.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Mechanical ventilation has been added to all bedroom windows. The ongoing maintenance will be provided throughout the year by the maintenance department |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom.There were no individual paper towels or mechanical dryers located at the sink area or inside the toilet/shower area located in the client bathrooms that were located between bedrooms.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Individual paper towels have been supplied to all individual bathrooms. Clients will be provided paper towels that will be stored in either a separate receptacle or a drawer adjacent to the sink, replenished by housekeeping on a daily or as needed basis. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure the hot water temperature may not exceed 120F.The employee bathroom in west short hall had a temp of 129F.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The water temperature was corrected at the time of inspection. It will be continually monitored during our monthly facility plant inspection(and submitted through the Pyramid intranet page under the safety and Environment) |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to store the utensils in a clean enclosed area.The clean eating utensils were not in an clean enclosed area. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The utensils have been covered and placed in individual sealed containers. Monitoring of covering the utensils will be incorporated into daily job duties. |
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 one of twelve client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client record # 3. Client # 3 was admitted on January 27, 2021 and was still active at the time of the inspection. A letter sent on February 1, 2021 was addressed to "To whom it may concern" providing admission and discharge information about the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All parties who facilitate completion of consents will participate in a re-training regarding the appropriate completion of consents and confidentiality restrictions by the department head or supervisor and it will be documented in their supervision notes.
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709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Based on three of four detox client records reviewed, the facility failed to provide a complete intake to include a physical examination.Client # 5 was admitted on September 7, 2020 and discharged on September 11, 2020. There was no physical examination documented in the client record. Client # 6 was admitted on August 11, 2020 and discharged on August 15, 2020. There was no physical examination documented in the client record. Client # 8 was admitted on May 27, 2020 and discharged on May 28, 2020. There was no physical examination documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physical examination will be completed on all detox clients, Director of Nursing will review requirements with the providers by 5/21/21. This will be monitored monthly through chart audits to ensure compliance by nursing leadership and will be implemented by 5/21/21. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on one of one applicable discharged client ' s record reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a follow-up to the client occur within 7 days of discharge.Client # 8 was admitted on May 27, 2020 and discharged on May 28, 2020. There was no follow-up information documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Case Management department received a re-training on 5/11/2021 regarding the importance of 7-day follow-up phone calls for all clients who discharge from the facility. This will be documented in their supervision notes, which will be available to review. This documentation will be located in the SA Call Log marked as follow-up outreach call. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on one of four patient records reviewed, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. Patient # 11 was admitted on December 24, 2020 and discharged on January 15, 2021. The patient was prescribed an agent on January 4, 2021 before having an initial face to face documenting current and one year addiction. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physician will make a face-to-face determination of physiological dependence and individual has been dependent for at least 1 year prior to admission to maintenance program. Provider will document this in the client record. Director of Nursing will review requirements with providers by 5/21/21. This will be monitored monthly through chart audits by nursing leadership to ensure compliance and implemented by 5/21/21. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on one of four patient records reviewed, the facility failed to provide a photograph onsite of each patient which includes the patient 's name and birth date in patient record # 12.Patient # 12 was admitted on August 19, 2020 and discharged on November 19, 2020. There was no patient identification documented in the patient record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Narcotic treatment program will maintain an onsite photograph of each patient that includes name and birth date. The photograph will be updated every 3 years. Intake staff will obtain photograph and upload to the client record. Nurse Manager will review requirements with assigned staff by 5/26/21. This will be monitored monthly through chart audits to ensure compliance. This will be implemented by 5/28/21. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on one of four patient records reviewed, the facility failed to provide documentation a narcotic treatment physician determined the patient 's initial and subsequent dose and schedule in patient record # 11. Patient # 11 was admitted on December 24, 2020 and discharged on January 15, 2021. There was no documentation of the patient ' s initial dose in the patient record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
(i & ii) -Physician will provide documentation of the patient initial and subsequent dose and schedule on physician order form. Each medication order and dosage change will be written and signed by the narcotic treatment physician/licensed practitioner. Director of Nursing will be review requirements with narcotic treatment physician/licensed practitioner and implement by 5/21/21. This will be monitored via monthly chart monitors to ensure compliance.
(iii - vi)Only licensed professionals will administer the medication. Only authorized staff and 1 patient receiving the medication, under direct observation, are permitted in the dispensing area at time to avoid disruption from others. Nurse Manager will review requirements with licensed staff in the next scheduled nursing meeting on Wednesday 5/26/21. Nurse Manager will complete spot checks monthly to ensure compliance; this will be effective 5/28/21.
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715.23(b)(3) LICENSURE Patient records
(b) Each patient file shall include the following information:
(3) A complete medical history
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Observations
Based on one of four patient records reviewed, the facility failed to provide a complete medical history in patient record # 12.Patient # 12 was admitted on August 19, 2020 and discharged November 19, 2020. There was not a complete medial history documented in the patient record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A complete medical history will be completed on all patients; Director of nursing will review requirements with the providers and implement by 5/21/21. This will be monitored monthly by nursing leadership through chart audits to ensure compliance.
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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on two of four patient records reviewed, the facility failed to provide documentation of an intake physical examination in patient records # 9 and 12. Patient # 9 was admitted on August 9, 2020 and was discharged on September 10, 2020. There was no documentation of a physical exam in the patient record. Patient # 12 was admitted on August 19, 2020 and was discharged on November 19, 2020. There was no documentation of a physical exam in the patient record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physical examination will be completed on all clients, Director of nursing will review with the providers and implement by 5/21/21. This will be monitored monthly by nursing leadership through chart audits to ensure compliance. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on one of four discharged patient records reviewed, the facility failed to provide an aftercare plan in patient record # 12.Patient # 12 was admitted on August 19, 2020 and was discharged on November 19, 2020. There was no aftercare plan documented in patient record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Although an aftercare plan was found to be present and timely in patient #12 upon review, the new Clinical Director will be available to provide specific and tailored support to auditors in future sessions. As of April 2021, Pyramid has implemented new procedures (a client navigation team now handles all scheduling of aftercare appointments) and discharge management plan document in order to increase compliance with discharge planning. The Clinical Director will also ensure all Clinical Supervisors understand the importance of documentation of aftercare plans in a timely manner by May 18 2021, in a leadership meeting. The clinical department will receive training for the new Discharge Management Plan by 5/13/2021. The monitoring of the discharge plans will take place in individual supervision and weekly group supervisions, and documented on the CARF supervision notes required per CARF standards. Clinical supervisors will also be responsible for monitoring (via 2 monthly chart audits, per counselor) their assigned counselor's charts for compliance with aftercare documentation on a monthly basis, also to be documented in the individual supervision notes. These audits and the supervision notes will be uploaded onto the " Duncansville Supervision Documentation" Smartsheet.Physical examination will be completed on all clients, Director of nursing will review with the providers and implement by 5/21/21.
Completion date: 11/12/2021 (6 months)
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on two of four client records reviewed, the facility failed to provide a complete intake to include a physical examination in client records # 2 and 3. Client # 2 was admitted on April 2, 2020 and discharged on June 29, 2020. There was no physical examination documented in the client record. Client # 3 was admitted on January 27, 2021 and was still active at the time of the inspection. There was no physical examination documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physical examination will be completed on all clients, Director of nursing will review with the providers and implement by 5/21/21. This will be monitored by nursing leadership through monthly chart audits to ensure compliance. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 six of seven applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information according to the facility policy and procedure manual in client records # 1, 2, 8, 9, 10 and 12.Client # 1 was admitted on January 23, 2021 and discharged February 20, 2021. There was no follow-up information documented in the patient record.Client # 2 was admitted on April 30, 2020 and discharged June 29, 2020. There was no follow-up information documented in the patient record.Client # 8 was admitted on May 27, 2020 and discharged May 28, 2020. There was no follow-up information documented in the patient record.Client # 9 was admitted on August 9, 2020 and discharged September 10, 2020. There was no follow-up information documented in the patient record.Client # 10 was admitted on January 4, 2021 and discharged February 2, 2021. There was no follow-up information documented in the patient record.Client # 12 was admitted on August 19, 2020 and discharged on November 19, 2020. There was no follow-up information documented in the patient record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Case Management department received a re-training on 5/11/2021 regarding the importance of 7-day follow-up phone calls for all clients who discharge from the facility. This will be documented in their supervision notes, which will be available to review. This documentation will be located in the SA Call Log marked as follow-up outreach call. |