INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 12-13, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
A physical plant inspection was conducted on October 12, 2017. Eight counselor and clinical supervisor offices were observed to not have coverings on the windows, failing to ensure privacy duirng counseling sessions.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Lead Housekeeper will hang window coverings on all counseling rooms with windows to ensure privacy/confidentiality. This will be completed by 11/13/17.
Program Director will inspect each counseling room that has a window.
This to be completed by 11/13/17 end of business day. |
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
Ten client records were reviewed on October 12-13, 2017. The facility failed to document a consent to release when consent was required in client record # 10.
Client # 10 was admitted into the partial hospitalization avtivity on 5/10/17 and was discharged from treatment on 6/7/17. A consent to release for the client's treatment funding source was not documented in the client's record. Additionally, documentation in the client's record indicated that a probation officer was notified of the client's discharge from treatment. A consent to release information to the probation officer 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 staff responsible for completing and documenting consents will be re-trained by the Medical Secretary Supervisor by December 10, 2017. The training will identify the proper points and signatures required with regard to a consent.
Completion of training will be verified by signature of attendance at the training.
HR Coodinator will maintain those records.
Month Chart Monitors will be completed by the Clinical Supervisors to ensure on-going compliance. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Three partial hospitalization client records were reviewed on October 13, 2017. The facility failed to document at least two individual counseling sessions weekly for client records, # 8, 9, and 10.
Client # 8 was admitted into treatment on 9/20/17 and was still active in treatment. Documentation in the client's record indicated that the client received one individual counseling session for the week of 10/1/17, specifically on 10/3/17.
Client # 9 was admitted into treatment on 5/3/17 and was discharged on 6/2/17. Documentation in the client's record indicated that the client attended one individual counseling session for the week of 5/14/17, specifically on 5/17/17.
Client # 10 was admitted into treatment on 5/10/17 and was discharged on 6/7/17. Documentation in the client's record indicated that the client attended one individual counseling session for the week of 5/21/17, specifically on 5/24/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Counselors will be re-trained by the Clinical Supervisor of each unit with regard to PHP loc specifically that clients attend two individual sessions per week.
Training will be completed no later than January 10, 2018. Training attendance will be verified by clinician's signature of attendance.
Verification and attendance verification will be monitored by the HR Coordinator.
Clinical Supervisors will ensure compliance through monthly chart monitors. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Three short-term detoxification client records were reviewed on October 12-13, 2017. The facility failed to document a complete client history during intake for client record # 3.
Client # 3 was admitted into detoxification treatment on 6/12/17, and was then transferred into inpatient rehabilitation treatment on 6/16/17. The client's personal history was not documented into the client's record prior to their discharge from detoxification treatment.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Intake staff will be re-trained by the Detox Manager with regard to documentation of client's personal history during the Intake process. Said training will be completed no later than January 10, 2018.
Staff will verify attendance at the training through their signature at time of attendance.
HR Coordinator will verify attendance and maintain records of the same.
Clinical Supervisors will complete monthly chart monitors to ensure on-going compliance. |
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
Four client records were reviewed for the use of Buprenorphine in the detoxification and maintenance treatment activities on October 12-13, 2017. The facility failed to have documented that a pregnant patient was fully informed of the possible risks to her unborn child while taking Buprenorphine in client record # 4.
Client # 4 was admitted into inpatient rehabilitation treatment on 10/1/17 and was still active in treatment.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #4 will be contacted by the Nurse Manager no later than December 15, 2017 and educated as this client has left treatment.
The Nurse Manager will re-train nursing staff with regard to providing patient information regarding possible risks to the unborn child while taking Buprenorphine use.
Training will be completed no later than December 1, 2017.
Attendance of training will be verified through attendance signature. All records of verification will be maintained by the HR Coordinator.
The Nurse Manager will complete monthly chart monitors so as to ensure on-going compliance. |
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
Four client records were reviewed for the use of Buprenorphine in detoxification and maintenance treatment activities on October 12-13, 2017. The facility failed to have documented an informed voluntary written consent prior to the administration of Buprenorphine in client record # 4.
Client # 4 was admitted into the inpatient rehabilitation activity on 10/1/17 and was still active in treatment. Documentation in the client's record indicated that the client received an initial dose of Subutex on 10/4/17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clients receiving Burenorphine for Detox and Inpatient maintenance will be provided Buprenorphine education by the nursing staff. This will be provided as well as informed written consent will be obtained prior to the administration of Buprenorphone per nursing staff.
Nursing staff will be re-trained by the Nurse Manager with regard to completion of the same. Training to be completed by the Nurse Manager prior to December 1, 2017.
Attendance at training will be verified by signature of attendance. Verification records will be maintained by the HR Coordinator.
Nurse Manager will verify on-going compliance through monthly chart audits. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Four client records were reviewed for the use of Buprenorphine in the detoxification and maintenance treatment activities on October 12-13, 2017. The facility failed to have documented a complete drug screen urinalysis prior to the administration of Buprenorphine in client records, #2 and 3.
Client # 2 was admitted into the short-term detoxification activity on 3/9/17 and was then transferred into inpatient rehabilitation activity on 3/13/17. Documentation in the client's record indicated that the client received an initial dose of Subutex on 3/9/17, at 8:30 am. The client's urinalysis results were reported by the lab on 3/10/17. The dipstick urinalysis test documented in the client's record was not dated.
Client # 3 was admitted into short-term detoxification activity on 6/12/17 and was then transferred into inpatient rehabilitation activity on 6/16/17. Documentation in the client's record indicated that the client received an initial dose of Subutex on 6/13/17, at 1:00 pm. The client's urinalysis results were reported by the lab on 6/14/17. The dipstick urinalysis test documented in the client's record was not dated.
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 the nursing staff.
The Nurse Manager will re-train nursing staff with regard to completing the Medication Administration Record to reflect the above.
Attendance at training will be verified by attendance signature. Verification of this record will be maintained by the HR Coordinator.
The Nurse Manager will monitor on-going compliance by completing monthly chart monitors. |
715.14(c) LICENSURE Urine testing
(c) A narcotic treatment program shall develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
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Observations
Four client records were reviewed for the use of Buprenorphine in the detoxification and maintenance treatment activities on October 12-13, 2017, the facility failed to implement complete urinalysis procedures that minimize the misidentification of urine specimens and ensure that the tested specimens can be traced to the donor. The facility has Department of Health and CLIA certificates as a laboratory, and may perform dipstick urinalysis tests onsite.
Records in question are client records # 2 and 3:
Client # 2 was admitted into the short-term detoxification activity on 3/9/17 and was then transferred into the inpatient rehabilitation activity on 3/13/17. The client's record contained a copy of a dipstick urinalysis container, with the test results marked on the container's label. The label did not record the client ' s ID and the date the urine specimen was collected.
Client # 3 was admitted into short-term detoxification activity on 6/12/17 and was then transferred into inpatient rehabilitation activity on 6/16/17. The client's record contained a copy of a dipstick urinalysis container, with the test results marked on the container's label. The label did not record the client ' s ID and the date the urine specimen was collected.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
urine specimen cups will be labeled with the client name, client ID and date test obtained to minimize mis-identification and to ensure the tested specimens can be traced to the donor. This task will be the responsibility of nursing staff.
The nursing staff will be re-trained by the Nurse Manager with regard to the avove tracking system. Verification of training attendance will be verified by staff signature attending training. HR Coordinator will verify training attendance and retain records of the same.
Nurse Manager will track on-going compliance by completing monthly chart monitors. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Four client records were reviewed for the use of Buprenorphine in the detoxification and maintenance treatment activities on October 12-13, 2017. The facility failed to document a written medication order from the physician for client record # 3.
Client # 3 was admitted into the short-term detoxification activity on 6/12/17 and was then transferred into the inpatient rehabilitation activity on 6/16/17. Documentation in the client's record indicated that the client received an initial dose of Subutex on 6/13/17, at 1:00 pm. A written medication order for the Subutex was not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A written medication order will be obtained by nursing staff for Buprenorphine prior to administration of the same. The order will be completed by the Practioner. The Nurse Manager will train nursing with regard to obtaining medication orders from Practioner no later than December 1, 2017.
Attendance at training will be verified by staff signature of attendance. HR Coordinator will maintain record of the same as well as verification.
On-going compliance of the same will be tracked through monthly chart monitoring of the same. |
715.17(c)(4)(i-viii) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
Four client records were reviewed for the use of Buprenorphine in the detoxification and maintenance treatment activities on October 12-13, 2017. The facility failed to maintain a complete medication administration record for client record # 3.
Client # 3 was admitted into the short-term detoxification activity on 6/12/17 and was then transferred into the inpatient rehabilitation activity on 6/16/17. A medication administration record sheet documented in the client's record identified Subutex as a prescribed medication. This sheet did not clearly specify the dates Subutex was administered to the client, and the charting month was not documented.
This finding was 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. The nursing staff will complete this task. Nurse Manager will re-train nursing staff with regard to the same.
Verification of training attendance will be substantiated by staff signature of attendance.
HR Coordinator will maintain verification records of the same.
Nurse Manager will verify on-going compliance by the completion of monthly chart monitors. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Four client records were reviewed for the inpatient rehabilitation activity on October 12-13, 2017. The facility failed to document a consent to treatment for client record # 7.
Client # 7 was admitted into the inpatient rehabilitation activity on 7/7/17 and was discharged from treatment on 7/18/17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All nursing staff as well as all medical secretarial staff will receive re-training with regard to proper documentation of Consent to Treatment in the official patient record.
Training will be provided by the Medical Secretary supervisor no later December 10, 2017.
Completion of training will be verified through attendant signature at the training. HR Coordinator will verify attendance and retain record of the same.
Nurse Manager will monitor on-going compliance by conducting month chart monitors. |