INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 13, 2010 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 and a plan of correction is due on November 12, 2010.
|
Plan of Correction
|
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the specific information to be disclosed and the purpose of disclosure in eight of eight client records.
The findings included:
Eight client records were reviewed on October 13, 2010. Eight client records required an informed and voluntary consent from the client; including the specific information to be disclosed and the purpose of disclosure. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record; including the specific information to be disclosed and the purpose of the disclosure. The facility failed to obtain an informed and voluntary consent from the client; including the specific information to be disclosed and the purpose of disclosure in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
On October 13, 2010, the facility director confirmed the consents to release information in client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include the specific information to be disclosed and the purpose of disclosure.
|
Plan of Correction
Theh consents will be revised to include one standard form with the specific information to be disclosed and the purpose of the disclosure. If a client is unwilling to release all of the information permitted as dictated in the confidentiality regulations, an alternate consent will be provided which more specifically indentifies the information permitted for release as indicated by the client's signature. Jason Beigay, Medical Records/Office Manager will monitor compliance on a monthly basis beginning immediately. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
|
Observations
Based on a review of the policy and procedure manual and an interview with the Nurse, the facility failed to document inspections of the medication storage area, as required by regulation.
The findings include:
The regulation requires an inspection of the medication storage area. On October 1, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an inspection of the medication storage area will be completed and documented monthly. On October 13, 2010, the inspections were reviewed for the months of October 2009 to September 2010. The facility failed to document the inspections of the medication storage area for the months of April 2010 and May 2010.
The Nurse confirmed that medication storage area inspections were not documented for the months April 2010 and May 2010.
|
Plan of Correction
Diamond Pharmacy will provide monthly inspections of all medication storage areas at Ridgeview. Jason Bolam, RN will assure compliance through monthly monitoring beginning November 1, 2010. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that provides a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in six of eight client records.
The findings included:
Eight client records were reviewed on October 13, 2010. Eight client records required an evaluation that provides a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation . The facility failed to obtain an evaluation that provides a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in client records # 1, 2, 3, 5, 6, and 8.
|
Plan of Correction
All counselors will recieve a comprehensive training on the written format of the Psychosocial Evaluation by February 1, 2011. The training will be facilitated by Clinical Coordinator,Amy Beuher and will include the importance of providing clinical recommendations in relation to the historical information provided during the assessment process. Monthly chart monitors will assess the quality of these documents ongoing. Marnie Hall, Program Director will ensure compliance. |