INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Chambersburg was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to make sure that all staff are trained for 6 hours in HIV/AIDS and at least 4 hours of TB/STD training in the required time frame. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Findings include:
Two personnel records were reviewed on September 29, 2014. Employee # 2 was hired January 9, 2012 and was required to have had HIV/AIDS training by January 9, 2014. As of the date of the licensing inspection the facility failed to document employee #2's HIV/AIDS training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 will have completed the training no later than December 31st, 2014. Director will ensure this occurs by scheduling the training with the staff and ensuring follow through. Director will ensure this does not occur again by having support staff schedule the required HIV/AIDS training within the first year in the event of cancelations of the training. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facility's CPR and first aid certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR and first aid.
The findings include:
Five employees CPR and first aid certification cards were reviewed on September 29, 2014. Four employees had current CPR & first aid certifications. The facility is open Monday, Wednesday and Thursday 9 am to 5:30 pm, Tuesday 8:30 am to 4:30 pm and Friday 8:30 am to 3 pm. At times, there are additional clinical appointments after business hours. Based on staff schedules presented there was no CPR & first aid coverage on Monday's and Wednesday's from 7pm to 7:30 pm.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The counselor with the missing CPR/first aid card is here with CPR certified counselors from 7pm-7:30pm. This will be changed on the counselors schedules to reflect this. Also, this counselor will either produce her CPR card by October 3rd, 2014 or will be enrolled in the next CPR certification training. In the meantime Director will ensure that this staff person is never on site without a staff person who is CPR/first aid certified by changing counselors schedules to reflect when they are here and ensuring that all counselors work their identified schedule. Director will ensure this does not reoccur by ensuring that all staff have their CPR/first aid certification to avoid scheduling conflicts and issues. Director will do this by ensuring all new staff either produce their active CPR card within one month of hire or enroll in the next available CPR training.
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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:
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in four of ten records reviewed.
The findings include:
Fifteen client records were reviewed on September 29, 2014. Ten of the fifteen was reviewed for informed and voluntary consent forms. The facility failed to document informed and voluntary consents in four client records, specifically records, #1, 2, 4 and 7.
Client record #1 - Fax sent to a government agency dated September 17, 2014 documented that the facility sent this government agency the client's recent drug test, copy of the client's initial evaluation, the client's most recent prescription and the client's initial assessment. The facility failed to have obtained an informed and voluntary consent for this government agency. Additionally, a fax dated September 17, 2014 to the client's insurance company exceeded 4 PA Code 255.5. The facility sent the following information: the client's recent drug test, copy of the client's initial evaluation, the client's most recent prescription and the client's initial assessment.
Client #2 - Fax dated September 12, 2014 to the client's insurance company exceeded 4 PA Code 255.5. The facility sent the following information: the client's recent drug test, copy of the client's initial evaluation, the client's most recent prescription and the client's initial assessment.
Client #4 - Fax dated July 30, 2014 to the client's insurance company exceeded 4 PA Code 255.5. The facility sent the following information: the client's recent drug test, copy of the client's initial evaluation, the client's most recent prescription and the client's initial assessment.
Client #7 - Letter sent to the client's employee assistant program dated August 6, 2014 exceeded 4 PA Code 255.5 by allowing the facility to release the following information: client's history, physical, medication review sheet and psychological assessment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director discussed PA Code 255.5 and insurance company and EAP requests with all administrative and clinical staff on 9/30/14 during a staff meeting. All questions were addressed. ON October 1, 2014 the LPN, who manages the Buprenorphine patients, was trained again on what we are allowed to release to insurance companies to authorize payment of medications, as well as having clients send their own grievances to DPW versus us faxing for them. Director will ensure compliance of confidentiality by discussing in weekly staff meetings, addressing any concerns with staff, and by doing random chart audits monthly. |