INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on September 10-12, 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 Erie 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
During a licensing inspection conducted September 4-5, 2019, the facility failed to provide documentation of the instruction of fire extinguisher and emergency training to all staff upon hire. Employee # 7 was hired as a counselor on August 11, 2019 and was still in this position at the time of the inspection. There was no documentation of the instruction of fire extinguisher and emergency training in the personnel file. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff as a part of their week of new hire process will receive training on fire safety and specific building procedures. Staff will have first day new hire orientation and work through basic office safety. HR is responsible for documentation of fire safety, Executive Director will monitor that proper training and documentation is secure for all new hires documentation to Erie Outpatient. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
During a Project Wide review of Policy and Procedures, the facilities Client Rights policy was missing - sex and marital status in 709.30 (2), and Reasons for removing sections shall be documented in the record in 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 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
During a licensing inspection conducted on September 10-12, 2019, the project failed to provide documentation of written acknowledgment by the client that the client had been made aware of their rights in client record # ' s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14. Acknowledgment of client rights did not include "sex" on discrimination in the provision of services. 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. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
During a licensing inspection conducted on September 10-12, 2019, the facility failed to provide documentation on monthly urine screenings for patient # 4.Patient # 4 was admitted on January 12, 2018 and was discharged on October 31, 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Erie Outpatient is completing weekly random urine screens on all Suboxone clients. These urine screens were faxed and paper copies that were placed in binders. Effective 9/12/19 all drug screens are running through Carelogic system electronically. This electronic process has improved from paper results for a more efficient communication of documentation for the medical and clinical teams. Medical team will be monitoring timeliness of drug screens, front office and Executive Director will ensure the follow up of this process. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
During a licensing inspection conducted on September 10-12, 2019, the project failed to provide documentation ensuring counseling services are provided according to the individual treatment and rehabilitation plan in four of seven records reviewed. Client # 1 was admitted on April 9, 2019 and was still an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan dated June 5, 2019 indicated an individual session monthly and group sessions three times a week. The chart's record of service and progress notes indicated that the client did not receive any individual sessions the month of August and did not receive three group sessions a week the months of June, July and August. Client # 3 was admitted on February 11, 2019 and was still an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan dated February 18, 2019 indicated an individual session monthly and group sessions weekly. The chart's record of service and progress notes indicated that the client did not receive any individual sessions the months of March, May, and July and did not receive any group sessions the month August.Client # 5 was admitted on February 7, 2019 and discharged on August 30, 2019. The comprehensive treatment and rehabilitation plan last updated July 12, 2019 indicated an individual session monthly and group sessions weekly. The chart's record of service and progress notes indicated that the client did not receive any individual sessions the month of June.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will be responsible for planning their monthly individuals within the first weeks of the start of the month. This will help to monitor clients with poor attendance and re-engage them for their session the same month. Clinical Supervisor will be monitoring monthly individual sessions in clinical supervisor and as a part of monthly chart monitors. Front office will be conducting daily reminder calls of clients individual sessions scheduled and Executive Director will be monitoring that this process is happening. |
709.93(a)(4) 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:
(4) Referral contact.
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Observations
During a licensing inspection conducted on September 10-12, 2019, the project failed to provide documentation of a completed client record to include referral contacts in three of seven records reviewed.Client # 3 was admitted on February 11, 2019 and was still an active client at the time of the inspection. There was not a referral contact documented in the client record.Client # 4 was admitted on January 12, 2018 and was discharged on October 31, 2018. There was not a referral contact documented in the client record.Client # 6 was admitted on April 9, 2019 and was discharged on July 8, 2019. There was not a referral contact documented in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Documentation was found for those assessments conducted in a hospital setting as unclear with referral source due to being in the paper chart. Facility will scan and upload all mobile documentation to ensure clear documentation of referral source contact. Facility will also be documenting through call log or memo to chart referral source communication, this will be monitored by compliance department and Clinical Supervisor in supervision sessions. Facility will continue to work through eliminating paper documentation and developing Carelogic forms that we are using paper in the system for clear communication. Front office staff effective 9/26/19 were also trained in full utilization of intake tracker documentation in Carelogic system. |