INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 1, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. Pine Ridge 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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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
A physical plant inspection was conducted on November 1, 2017. A shower in the 2nd floor client bathroom of B House was observed to have substantial mold on the tiles. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The bathroom on 2nd floor of B House was cleaned thoroughly on November 4, 2017 to remove all mold. Bathroom cleanliness was reviewed with all clients at the facility on November 6, 2017 during life skills group and will continue being an ongoing topic for this group. Pyramid maintenance will look at the need for upgrades to this bathroom and replace fixtures as needed by January 31,2018. Tech Supervisor will monitor bathrooms daily to ensure proper cleanliness. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Fire drills were reviewed on November 1, 2017, for the period of December 2016 - October 2017. Documentation on the fire drills indicated that a fire alarm or smoke detector was not set off during each fire drill conducted during the reviewed time period. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Maintenance staff will train all staff on utilization of the fire alarm system by December 30,2017. All buildings will be done together, during each drill. Staff will contact the alarm company prior to running every drill, to ensure the alarm company is aware the facility is conducting a drill. Risk Committee and Program Director will ensure that this procedure is being followed for every fire drill. |
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.
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Observations
Six client records were reviewed on November 1, 2017. The facility failed to obtain a valid informed and voluntary consent to release information when applicable for client records # 1 and 2. Client # 1 transferred into treatment at this facility on 8/3/17 and was still active in treatment. A valid consent to release information to the client's treatment funding source, a medical assistance provider, was not documented in the client's record. Client # 2 was admitted into treatment on 7/5/17 and was still active in treatment. A consent to release information to the client's treatment funding source, a medical assistance provider, was not documented in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Administrative assistant was retrained on completion of consents and intake paperwork on November 6, 2017. Clinical staff will monitor all charts upon admission to ensure proper consents are in place during first initial session with client. Program Director and Lead Counselor will monitor consents as part of the monthly chart audit. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Six client records were reviewed on November 1, 2017. The facility failed to maintain a complete medication administration record for client records # 1, 2, 3, and 6. Client # 1 transferred into treatment at this facility on 8/3/17 and was still active in treatment. A medication administration record sheet documented in the client's record indicated that PRN medications were administered to the client. However, this sheet did not clearly specify the dates the medications were administered to the client, and the charting month was not documented. Client # 2 was admitted into treatment on 7/5/17 and was still active in treatment. Three medication administration record sheets documented in the client's record indicated that prescription medications were administered to the client. However, these sheets did not clearly specify the dates the medications were administered to the client, and the charting months were documented. Client # 3 was admitted into treatment on 3/24/17 and was still active in treatment. Seven medication administration record sheets documented in the client's record indicated that prescription medications were administered to the client. However, these sheets did not clearly specify the dates the medications were administered to the client, and the charting months were not documented. Client # 6 was admitted into treatment on 5/4/17 and was discharged on 8/30/17. Two medication administration record sheets documented it the client's record indicated that prescription medications were administered to the client. However, these sheets did not clearly specify the dates the medications were administered to the client, and the charting months were not documented. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The medication administration record will be complete to include date and month of administration. This will be completed by Medication technicians and will be tracked through monthly chart monitors by the Lead Nurse. The Medication technicians will be trained and this will be in effect by December 30, 2017.
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility's incident report log was reviewed on November 1, 2017. The facility failed to report to the Department a documented event at the facility that required the presence of police personnel, occurring on October 20, 2017. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Coordinator for Pyramid Healthcare retrained staff at Pine Ridge Manor on November 3, 2017 regarding criteria for completion of critical incidents. All staff were given a copy of the policy of reporting critical incidents on November 1, 2017.
All staff will complete incidents reports at time of incident. The report then goes directly to Program Director for review. Program Director will review incident report immediately, ensuring that appropriate treatment or intervention was initiated. Program Director will ensure appropriate authorities were notified and appropriate documentation was completed. Clinical Director and Program Director will review all incident reports to ensure accuracy and appropriate procedures followed. |
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
Six client records were reviewed on November 1, 2017. The facility failed to document a treatment plan update at least every 30 days for client records # 1, 2, 4, and 6. Client # 1 transferred into treatment at this facility on 8/3/17 and was still active in treatment. A comprehensive treatment plan was completed for the client on 8/14/17. The first treatment plan update documented in the client's record was completed on 9/28/17. A subsequent treatment plan update was due to be completed by 10/28/17, and one was not documented in the client's record. Client # 2 was admitted into treatment on 7/5/17 and was still active in treatment. A treatment plan update was completed for the client on 8/10/17. A subsequent treatment plan update was then completed on 9/14/17. Client # 4 was admitted into treatment on 3/1/17 and was discharged on 5/9/17. A comprehensive treatment plan was completed for the client on 3/8/17. A subsequent treatment plan update was then completed for the client on 4/13/17. Client # 6 was admitted into treatment on 5/4/17 and was discharged on 8/30/17. A treatment plan update was completed for the client on 7/6/17. A subsequent treatment plan update was due to be completed by 8/6/17, and one was not documented in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clinical staff were retrained on requirements for completion of treatment plan reviews during clinical team meeting on November 6, 2017.Clinical staff will ensure updates are being completed, reviewed with, and signed off with the client, within the required time frame. Lead counselor and Program Director will complete monthly chart audits to ensure compliance. |