INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, 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 inspection, client records were reviewed on October 1, 2020 and the physical plant inspection was conducted on October 22, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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 lounge on the second floor had four chairs in need of repair due to holes and tears. The men's detox lounge had one couch in need of repair due to holes and tears.This was reviewed with the facility staff during the licensing process.
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Plan of Correction
Four new chairs and one couch were ordered for the men's detox lounge and second floor lounge as of 12/3/2020.Furniture is expected to be delivered by 2/1/2021, pending at this point. Covid related obstacles (later delivery dates) may interfere with this date so this is an approximate date. Maintenance and housekeeping will check the lounges on a weekly basis as of 12/3/2020 for any additional tears, holes or rips. Maintenance requests will be filled out as necessary for any furniture needing repair or replacement. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a review of the facility ' s policies and procedures for the storage of Vivitrol, it was found they failed to keep two boxes of Vivitrol in a locked refrigerator. This was reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 12/3/2020, Nurse Manager will provide training for new staff or re-training to all nurses regarding the safekeeping of Medication Assisted Treatment (MAT). The Nurse Manager will ensure all staff are re-educated on this procedure by 1/3/2021. This will be logged into a training sign-in sheet or team meeting notes. Nurse manager will do rounds at the end of each shift to make sure all MAT medication is kept in locked refrigerator effective immediately.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of seven clients on October 1, 2020, the project failed to orient four out of seven clients to project policies. Client #9 was admitted on July 28, 2020 and was current at the time of the inspection. Client #9 was not oriented to project policies. Client #10 was admitted on July 21, 2020 and was current at the time of the inspection. Client #10 was not oriented to project policies. Client #13 was admitted on July 21, 2020 and was discharged on September 24, 2020. Client #13 was not oriented to project policies. Client #14 was admitted on June 7, 2020 and was discharged on September 24, 2020. Client #14 was not oriented to project policies. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Our intake supervisor retrained current intake staff members on orienting clients on project familiarization and what documents to upload in the document library on 10/11/2020 and 10/12/2020. A sign- in sheet has been obtained to show that this task was completed. New staff members were trained on 11/11/20, also documented in a sign in sheet. All items: Project policies, hours of operation, fee schedule, and services provided are a part of the IP assessment bundle and client orientation which are all housed on the same form which was missed in error for these clients notated. Current clients will be given the correct paperwork and sign the orientation checklist once gone over with staff. Intake supervisor will complete randomized quarterly audits on intake staff members compliance on this matter. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of seven clients on October 1, 2020, the project failed to orient four out of seven clients to hours of operation. Client #9 was admitted on July 28, 2020 and was current at the time of the inspection. Client #9 was not oriented to hours of operation. Client #10 was admitted on July 21, 2020 and was current at the time of the inspection. Client #10 was not oriented to hours of operation. Client #13 was admitted on July 21, 2020 and was discharged on September 24, 2020. Client #13 was not oriented to hours of operation. Client #14 was admitted on June 7, 2020 and was discharged on September 24, 2020. Client #14 was not oriented to hours of operation. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Our intake supervisor retrained current intake staff members on orienting clients on the hours of operation, as well as making sure the documents are uploaded in the document library. This was on 10/11/2020 and 10/12/2020. A sign-in sheet has been obtained to show that this task was completed. New staff members were trained on 11/11/20, also documented in a sign in sheet. All items: Project policies, hours of operation, fee schedule, and services provided are a part of the IP assessment bundle and client orientation which are all housed on the same form which was missed in error for these clients notated. Current clients will be given the correct paperwork and sign the orientation checklist once gone over with staff. Intake supervisor will complete randomized quarterly audits on intake staff members to ensure compliance on this matter.
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709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of seven clients on October 1, 2020, the project failed to orient four out of seven clients to fee schedule. Client #9 was admitted on July 28, 2020 and was current at the time of the inspection. Client #9 was not oriented to fee schedule. Client #10 was admitted on July 21, 2020 and was current at the time of the inspection. Client #10 was not oriented to fee schedule. Client #13 was admitted on July 21, 2020 and was discharged on September 24, 2020. Client #13 was not oriented to fee schedule. Client #14 was admitted on June 7, 2020 and was discharged on September 24, 2020. Client #14 was not oriented to fee schedule. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Our intake supervisor retrained current intake staff members on orienting clients to the fee schedule, as well as making sure the documents are uploaded in the document library. This was on 10/11/2020 and 10/12/2020. A sign-in sheet has been obtained to show that this task was completed. New staff members were trained on 11/11/20, also documented in a sign in sheet. All items: Project policies, hours of operation, fee schedule, and services provided are a part of the IP assessment bundle and client orientation which are all housed on the same form which was missed in error for these clients notated. Current clients will be given the correct paperwork and sign the orientation checklist once gone over with staff Intake supervisor will complete randomized quarterly audits on intake staff members to ensure compliance on this matter. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of seven clients on October 1, 2020, the project failed to orient four out of seven clients to services provided. Client #9 was admitted on July 28, 2020 and was current at the time of the inspection. Client #9 was not oriented to services provided. Client #10 was admitted on July 21, 2020 and was current at the time of the inspection. Client #10 was not oriented to services provided. Client #13 was admitted on July 21, 2020 and was discharged on September 24, 2020. Client #13 was not oriented to services provided. Client #14 was admitted on June 7, 2020 and was discharged on September 24, 2020. Client #14 was not oriented to services provided. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Our intake supervisor retrained current intake staff members on orienting clients to services provided, as well as making sure the documents are uploaded in the document library. This was on 10/11/2020 and 10/12/2020. A sign-in sheet has been obtained to show that this task was completed. New staff members were trained on 11/11/20, also documented in a sign in sheet. All items: Project policies, hours of operation, fee schedule, and services provided are a part of the IP assessment bundle and client orientation which are all housed on the same form which was missed in error for these clients notated. Current clients will be given the correct paperwork and sign the orientation checklist once gone over with staff. Intake supervisor will complete randomized quarterly audits on intake staff members to ensure compliance on this matter. |