INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7-9, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc. Pyramid Pittsburgh 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(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
The facility failed to ensure that all of its staff received the mandatory training hours in communicable diseases within the required time frames. A total of 16 personnel files were reviewed as part of the presubmission process, during the administrative review conducted at the project headquarters and at the on-site inspection.Staff Person #15 was hired as a support staff member on February 19, 2016, and was required to have six hours of HIV/AIDS training by February 19, 2018, but the staff person did not receive the six hours of training until March 13, 2018. Staff Person #16 was hired as a support staff person on December 23, 2015, and was required to have six hours of HIV/AIDS by December 23, 2017, but the staff person did not have the six hours of training at the time of the on-site inspection. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Deficient staff will be enrolled in needed trainings as soon as possible so they will no longer be deficient. If staff are on leave, this will be documented as to why they missed training, due to personal leave, etc. HR will send out notifications Monthly when trainings are available, and send a list to supervisors what staff need the training. This has begun starting 9-1-18. Supervisors will then sign up staff and notify them of the training so they can be in attendance.
If the training is cancelled or the staff is unable to attend, we will search for that training in the area to ensure the staff are not out of compliance with training hours. |
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
The facility failed to ensure that cold and frozen foods were kept at the required temperatures. The temperature for the walk-in freezer was tested at 10 degrees Fahrenheit. The temperature for the walk-in refrigerator was tested at 45 degrees Fahrenheit. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Refrigerators/Freezers were checked out after 8/9/18 inspection to ensure they were all working properly. Checks are completed on the refrigerators/freezers twice daily to ensure that the temperatures are correct. These are conducted at the start of the kitchen shift in the morning and end of each shift in the evening. If they are not within normal ranges, the repair technicians are contacted by the supervisor to rectify the situation. We have not had any further issues following the 8/9/18 inspection. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to ensure that it complied with 4 Pa. Code 255.5 in the information that it released to government officials. With the written consent of a patient the facility may only release to government officials: (1) Whether the client is or is not in treatment. (2) The prognosis of the client. (3) The nature of the project. (4) A brief description of the progress of the client. (5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse. Patient #5 was admitted to treatment June 8, 2018. The patient's record documented that two of the patient's pay stubs were emailed to the county assistance office on June 18, 2018. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Starting 9-1-18 clients applying for Medical Assistance will mail their pay stubs to the assistance office if they are required from them to obtain insurance. Pyramid Healthcare is also working with Director of Compliance to work on a fax cover sheet that does not have any Pyramid Information on it, and if the client wants to fax the information, they will be able to do so using with the cover sheet and fax the information over themselves. |
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
The facility failed to ensure that it notified patients of their rights to appeal a decision to limit patients' access to their client records. A total of fourteen patients records were reviewed during the on-site inspection. None of the fourteen records included written acknowledgement that patients had the right to appeal a decision limiting their access to their patient records. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Effective 10-1-18, Clients handbooks will be updated to add that the "clients have the ability to appeal decisions limiting access to records". Client handbook is given to all clients entering treatment and it is reviewed with them at that time, so all clients entering treatment will receive this information. All clients then sign an orientation checklist that details that they reviewed the client handbook, rules, etc. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to document the emergency contact information for patients prior to beginning narcotic treatment. Patient #2 was admitted for narcotic treatment on March 3, 2018 and was dosed with a narcotic agent on March 4, 2018. Patient #3 was admitted for narcotic treatment on February 13, 2018 and was dosed with a narcotic agent on February 13, 2018. Patient #4 was admitted for narcotic treatment on April 30, 2018 and was dosed with a narcotic agent on May 1, 2018. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
During the nursing meeting on 9-25-18, it was reviewed with Nursing staff, any staff completing an intake should make every attempt to obtain an emergency contact, and if a client declines to list one it must be documented in the chart. Program Director met with Intake Supervisor on 9-4-18 to review the same information with Intake Supervisor, so she could also pass it along to intake staff. If a client declines to list one, a memo to chart will be entered by nursing/intake staff. Once a client meets with a detox specialist/counselor, they will also try to obtain an emergency contact from them and document if they accept or decline. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to inform all female patients of the possible risks of use or withdrawal from the narcotic agent administered by the facility. Patient #2 was admitted for narcotic treatment on March 3, 2018, and was dosed with buprenorphine on March 4, 2018, but the patient was not given information on the risks of buprenorphine use or withdrawal to unborn children until March 8, 2018. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
During the nursing meeting on 9-25-18, it was reviewed with Nursing staff, any staff completing an intake should ensure that all female clients entering treatment receive paperwork informing them of the risks of buprenorphine use or withdrawal to their unborn children. and sign off on it. We currently have the paperwork in the facility, staff needs to ensure, however, it is being signed upon review. Program Director met with Intake Supervisor on 9-4-18 to review the same information with supervisor, so she could also pass it along to staff completing intakes. Nursing Supervisor implemented a Checklist for intakes, so that they ensure all documentation is being completed and signed off on by the client. This was reviewed during 9-25-18 meeting and this will begin 10-1-18. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The facility failed to ensure that it updated patient treatment plans according to the length of the patients' treatment regimens in two of six applicable records. The facility has treatment regimens for patients that are twenty-eight days or less, and treatment regimens that range from twenty-eight days to as long as ninety days. Patient # 11 was admitted to treatment on February 27, 2018 and was discharged on March 20, 2018. The patient's individualized treatment plan was dated February 28, 2018, but no update was documented. Patient # 14 was admitted to treatment on March 29, 2018 and was discharged on June 4, 2018. The patient's individualized treatment plan was dated March 29, 2018 but no update was documented. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Effective 9-30-18, Clinical Director and Clinical Supervisor will do bi weekly chart audits to ensure compliance of clinical documentation. This information will be reviewed with staff during bi weekly supervision with them. Any staff who is deficient on this, will be put on a performance improvement plan. |