INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November
9-10, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. Transitions 2 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 and a plan of correction is due on December 10, 2009.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, a review of the facility summary report, and a conversation with the director, the facility failed to provide documentation of HIV/AIDS and TB/STD training for five of nine personnel.
The findings include:
Five personnel records were reviewed on October 2, 2009. Two personnel qualifications were reviewed on November 10, 2009. The facility summary report was reviewed on November 10, 2009. Nine personnel were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for personnel records # 8, 9, 10, 11, and 12. This was confirmed by the Assistant Director of Nursing on November 10, 2009.
Employee # 8 is a support staff and was hired March 1, 2004. HIV/AIDS and TB/STD training was to be completed within two years of hire, by March 1, 2006. The facility failed to provide documentation of HIV/AIDS training as of November 10, 2009.
Employee # 9 is a support staff and was hired November 29, 2006. HIV/AIDS and TB/STD training was to be completed within two years of hire, by November 29, 2008. The facility failed to provide documentation of TB/STD training as of November 10, 2009.
Employee #10 is a support staff and was hired August 3, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by August 3, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of November 10, 2009.
Employee #11 is a support staff and was hired July 18, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by July 18, 2009. The facility failed to provide documentation of TB/STD training as of November 10, 2009.
Employee #12 is a support staff and was hired October 24, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by October 24, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of November 10, 2009.
|
Plan of Correction
Each Transitions employee will be required to know the number of yearly training hours they must accumulate for their specific job classification. It will be the duty of each employee's supervisor to ensure that training hour requirements are satisfied. The program director will have oversight to ensure that all supervisory staff are scheduling their employee's for the required amount of training hours and are doing so in a timely fashion. This system will be in place by January 4, 2010. |
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in five of eight client records.
The findings include:
Eight client records were reviewed on November 9 - 10, 2009. Eight client records were required to include an informed and voluntary consent from the client prior to the disclosure of information. Five of the eight records, #1, 3, 5, 6 and 8, did not include completed consents prior to the disclosure of information.
Client record #1 included a release of information to another treatment provider that did not include the specific information to be disclosed. The specific information section on the release of information form had all "no's" checked. In addition, the purpose section of that release of information did not include a relevant purpose/reason for the disclosure of the information. The purpose was listed as "document DOB copy". This was signed by client and the staff member on 11-6-09. The admission date for this client was 11-6-09.
Client record #3 included a release of information to another treatment provider that did not include the specific information to be disclosed. The specific information section on the release of information form was blank. This was signed by client and the staff member on 10-20-09. The admission date for this client was 10-20-09.
Client record #5 included the disclosure to another treatment provider via documentation of a fax form that was faxed on September 2, 2009 at 4:21 PM and a phone call on September 2, 2009 at 4:15 PM. There was no documentation of a consent form allowing for the disclosure of information to this treatment provider. This record also included documentation of phone contact on 7-28-09 at 9:50 am and 7-29-09 to Washington County Drug and Alcohol Commission. There was no documentation of a consent form allowing for the disclosure of information to Washington County Drug and Alcohol Commission. The admission date for this client was 7-28-09.
Client record #6 included two release of information forms for the clients girlfriend. There was one release of information form for the clients girlfriend that was signed by the client and the staff member on 8-24-09, and that form included all of the required documentation. The other release of information form for the client's girlfriend was signed by the client and the staff member on 8-27-09, did not include the specific information to be disclosed or the purpose of the disclosure. The specific information section and the purpose section on the release of information form were blank. These sections were blank when they were reviewed on 11-9-09 at 2:00 PM. The clinical supervisor approached me with the clinical record on 11-10-09 at 1:30 PM to question the issue, the release form dated 8-27-09 was completed. The admission date for this client was 8-25-09.
Client record #8 included a release of information to the client's mother that did not include the specific information to be disclosed. The specific information section on the release of information form was blank. This was signed by client and the staff member on 10-30-09.
There was a release of information for Erie County Probation that allows for the disclosure of information that exceeds the limitations imposed at 4 Pa. Code Subsection 255.5(b). The specific information to be disclosed includes the history and physical examination, treatment progress reports, psychiatric evaluation, general progress update, and M.A.R.s (Medication Administration Record). This form was signed by the client and the staff member on 11-5-09. The admission date for this client was 10-29-09.
|
Plan of Correction
An informed and voluntary consent from the client will be completed prior to disclosure of client information. All consents will be thoroughly completed and will include specific information to be disclosed regarding the client. To ensure compliance with this plan of correction, inpatient rehabilitation charts will be monitored on a monthly basis by the clinical supervisor. Inpatient detoxification charts will be monitored by the medical administrative assistant on a monthly basis. This system will be in place by 02/01/2010. |
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.
|
Observations
Based on client record review and a conversation with the staff, the facility failed to document a follow up attempt in two of three client records.
The findings include:
Eight client records were reviewed on November 9 - 10, 2009. Four of the client records reviewed were from the inpatient non-hospital - short-term detoxification activity. A follow up attempt was required to be documented in three of the four client records. The facility did not document a follow up in two client records, # 3 and #4. The facility policy states that follow up will be attempted within seven days of discharge.
Client #3 was admitted on 10-20-09 and discharged on 10-24-09. A follow up attempt was due on 10-31-09. There was no documentation of a follow up attempt as of November 10, 2009.
Client #4 was admitted on 9-14-09 and discharged on 9-19-09. A follow up attempt was due on 9-26-09. There was no documentation of a follow up attempt as of November 10, 2009.
|
Plan of Correction
The detoxification behavioral health technician will set up appropriate aftercare for the detox client and will document this appointment on the aftercare form. This aftercare form will be given to the receptionist within 2 days of the client's discharge. The receptionist will be responsible for making follow-up calls within 7 days of that client's discharge from the detoxification unit. The receptionist will document all follow-up contact on the aftercare form. This procedure will be montitored weekly by the program director. This system will be in effect by 1-04-2010. |
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.
|
Observations
Based on client record review and a conversation with the staff, the facility failed to document a follow up attempt in one of two client records.
The findings include:
Eight client records were reviewed on November 9 - 10, 2009. Four of the client records reviewed were from the inpatient non-hospital - residential treatment and rehabilitation activity. A follow up attempt was required in two of the client records. The facility did not document a follow up in one client record, # 5. The facility policy states that follow up will be attempted within seven days of discharge.
Client #5 was admitted on 7-28-09 and discharged on 9-21-09. A follow up attempt was due on 9-28-09. There was no documentation of a follow up attempt as of November 10, 2009.
|
Plan of Correction
The aftercare coordinator will set up appropriate aftercare for the client and will document this appointment on the behavioral health communication form (orange sheet)which is given to the primary counselor. The client's primary counselor will document this appointment date and time on the aftercare plan form and will make a copy of this form which will be placed in the client's chart. The original aftercare plan form will be given to the receptionist within 2 days of the client's discharge. The receptionist will be responsible for making follow-up calls within 7 days of that client's discharge. The receptionist will document all follow-up contact on the aftercare form. This procedure will be montitored weekly by the program director. This system will be in effect by 1-04-2010. |