INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2016 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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709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to obtain informed and voluntary consent forms for the disclosure of information contained in the client record in nine of ten client records reviewed on December 5, 2016.
Ten client records were reviewed. Ten records required an informed and voluntary consent to release client information. The facility failed to obtain an informed and voluntary consent to release information in client records # 1, 2, 3, 4, 5, 6, 8, 9 and 10.
The consent to release information form states that revocation must be in writing. 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.
In addition, consents to release information to criminal justice authorities were observed to include a statement that the consent could not be revoked. There were no court orders mandating treatment documented for these clients and therefore, the consents could be revoked verbally or in writing at any time.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent, including acknowledgement that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 2017. Completion of training will be verified by post test completion and monitored by Human resources Coordinators.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
The facility failed to document that a copy of signed consents were offered to the client in nine of ten client records reviewed on December 5, 2016.
Ten client records were reviewed. Client records # 1, 2, 3, 4, 5, 6, 8, 9 and 10 included at least one signed consent in which the client was not offered a copy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent, including acknowledgement that a copy was offered to the client as well as the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 2017. Completion of training will be verified by post test completion and monitored by Human resources Coordinators.
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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility failed to document that verbal orders were signed by the prescribing physician within three business days, in four of four client records reviewed on December 5, 2016.
Ten client records were reviewed. Four client records documented verbal orders. The facility did not document that verbal orders were signed within the required timeframe by the prescribing physician in client records # 7, 8, 9 and 10. The prescribing physician's signatures were not dated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Suboxone/Buprenorphine Intake Form is no longer used. Verbal orders are rarely used in current program. If a verbal order would be received from a prescriber, the nurse would document the order in the client's paper chart on the physician order sheet. The page would be flagged to be signed by prescriber within 24 hours of receiving and documenting the order. The nurse would also document a note in the client's electronic record in the nursing note. This corrective action will be monitored by the Director of Nursing and Facility Director. Supervision and chart monitors will be completed in order to monitor and ongoing compliance with this correction. The corrective action date is as of the date of the survey December 5, 2016. |