INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 13-14, 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. Quakertown 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
During a licensing inspection conducted on August 13-14, 2019, the facility failed to provide documentation of a written individual training plan for employee's # 10, 11, 12, 13, 14, and 15.
Employee # 10 was hired as a support staff on July 31, 2017 and was still this position at the time of the inspection.
Employee # 11 was hired as a support staff on April 18, 2019 and was still this position at the time of the inspection.
Employee # 12 was hired as a support staff on May 7, 2018 and was still this position at the time of the inspection.
Employee # 13 was hired as a support staff on July 15, 2019 and was still this position at the time of the inspection.
Employee # 14 was hired as a support staff on June 29, 2016 and was still this position at the time of the inspection.
Employee # 15 was hired as a support staff on July 12, 2016 and was still this position at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
POC: Executive Director will ensure that all Department Managers, including regional managers whose employees work at Quakertown, monitor their assigned yearly staff training plans with annual evaluations, first month of the year, and upon new hire, and create training plan binder for all employees to keep in one central location. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. Target date for completion is 10/1/19. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
During a licensing inspection conducted on August 13-14, 2019, the facility failed to provide documentation that employee's #10, 14 and 15 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee # 10 was hired as a support staff on July 31, 2017 and was due to have the communicable disease trainings no later than July 31, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee # 14 was hired as a support staff on June 29, 2016 and was due to have the communicable disease trainings no later than June 29, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee # 15 was hired as a support staff on July 12, 2016 and was due to have the communicable disease trainings no later than July 12, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All department heads, including regional managers whose employees work at Quakertown, and AA for the facility will track/monitor completion of staff Communicable Diseases training for all department employees and report in monthly leadership meeting. Executive Director will ensure that all Department Managers monitor their assigned staff for compliance of Communicable Diseases training attendance through supervision. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. Target date for completion is 10/1/2019. All outstanding employees to attend next scheduled trainings. |
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 August 13-14, 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, and 7. 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 Pyramid Clinical Forms Committee will be updating the client rights 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, and importance of having client rights form signed by all clients, by September 15, 2019. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
During a licensing inspection conducted on August 13-14, 2019, the facility failed to provide documentation of a medication inspection conducted at least quarterly.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Executive Director and facility Nurse Manager will create a medication cart inspection checklist to be completed at minimum monthly by medical staff, and Nurse Manager will review quarterly for compliance, and keep record of all medication cart inspection in medical room. Target date of completion: 10/1/19 |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
During a licensing inspection conducted on August 13-14, 2019, the project failed to provide documentation notifying the client in writing the decision to involuntarily terminate the client's treatment at the project.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review with clinical staff the need to notify a client in writing of the decision to involuntarily terminate the client from treatment at the facility, which shows the right to appeal the decision. The written notice will include the reasons for the termination, and a memo to chart noting the letter was provided to the client will be completed by clinical staff.
Clinical Director and or Regional Clinical Coordinator will monitor compliance in this area through monthly documented supervision with clinical and completion of a minimum of bimonthly open and closed chart audits.
Target date for completion is 10/1/2019
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
During a licensing inspection conducted on August 13-14, 2019, the facility failed to provide documentation of an informed, voluntary, written consent before an agent being administered to patient # 5 for either maintenance or detoxification treatment.
Patient # 5 was admitted on October 17, 2018 and was discharged on December 6, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will review with Nurse Manager and MAT provider need for thorough completion of the IP MAT induction bundle in the electronic record, including informed consent. Target date 10/1/19.
Nurse manager will ensure compliance with this by conducting monthly chart audits on all medicated assisted treatment clients in our care for open and closed charts, and if any documentation is missing, have the MAT provider complete
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715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
During a licensing inspection conducted on August 13-14, 2019, the facility failed to provide documentation that the comprehensive treatment plan was developed with patient # 5. There was no acknowledgement of the patient or counselor signature and it was not documented in the progress notes.
Patient # 5 was admitted on October 17, 2018 and discharged on December 6, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review in weekly clinical team meeting by 10/1/19 with clinical staff the required documentation and signature timelines of treatment plans to ensure compliance.
Clinical Director and or Regional Clinical Coordinator will monitor compliance in this area through monthly documented supervision with clinical staff and completion of a minimum bimonthly open and closed chart audits.
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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
During a licensing inspection conducted on August 13-14, 2019, the project failed to provide documentation of a complete client record to include follow-ups in client records # 5, 6, and 7.
Client # 5 was admitted on October 17, 2018 and discharged on December 6, 2018.
Client # 6 was admitted on May 24, 2019 and discharged on June 20, 2019.
Client # 7 was admitted on June 11, 2018 and was discharged on July 9, 2018.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed this regulation and documentation timelines for follow up calls with facility administrative assistant on 8/26/19.
Clinical Director and or Regional Clinical Coordinator will monitor compliance in this area through completion of a minimum of bimonthly open and closed chart audits. Target date for monitoring 10/1/2019
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