INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28, 2013, by staff from the Program Licensure Division. 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. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director in one of one personnel records.
The findings include:
Four personnel records were reviewed on August 28, 2013. One personnel record pertained to the project director and was required to complete 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
A discussion with the facility director revealed that the training certificates for the project director were not available for review.
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Plan of Correction
Facility will ensure that project director's training certifications are available for onsite reviews prior to date of inspections. These training certifications will be uploaded by Human Resources onto the network for all facilities to be able to access after completion of trainings. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential 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
Based on observation during the physical plant inspection, the facility failed to ensure privacy so that counseling session could not be seen outside the counseling room.
The findings include:
The physical plant inspection took place on August 29, 2013. During the inspection, the downstairs group room and three counselor offices each had two windows that failed to include window coverings. This allowed counseling and group sessions to be seen from outside the counseling room.
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
Window coverings for all back windows were put up on 9/11/2013. The coverings will remain there, and ensured that they remain there, by facility director's daily observation. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of administrative documentation, the facility failed to complete a performance report to summarize progress towards meeting goals and objectives for the fiscal year July 1, 2012 to June 30, 2013.
The findings include:
The facility director was asked to provide a written progress report that summarized the progress towards meeting the 2012-2013 goals and objectives. The facility director was unable to provide any documentation.
This is a repeat citation from the licensing inspection that was conducted on August 29-30, 2012.
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Plan of Correction
Facility Director will ensure that the written progress report that summarizes the progress towards meeting goals and objectives be available for onsite reviews. These documents will be available with the goals and objectives on the network for facility access. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on the review of patient records and staff interviews, the facility failed to have a system for maintaining an onsite photograph of each patient for the purpose of verifying the correct identity of a patient prior to administration of an agent.
The findings include:
Five patient records were reviewed on August 28, 2013. Two records were reviewed for documentation of patient identification for the purpose of verifying the patient's identity prior to the administration of an agent. Patient records # 1 and 2 failed to include documentation of patient identification in the the record.
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Plan of Correction
Patients will be accurately identified prior to receiving prescriptions for Suboxone through obtaining photo identification and maintaining copies in the patient file. If a patient has been in the program for 3 years, an updated photo identification will be required to update in their file. Facility director and medical director will ensure compliance with this through random chart audits, as well as continued trainings with the LPN or RN, who manages the case files.
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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
Based on review of the patient records, the facility failed to obtain a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory in one of two records.
The findings include:
Five patient records were reviewed on August 28, 2013. Two patient records were required to complete a drug screen urinalysis prior to the administration of Suboxone, a narcotic agent. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to obtain a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent in record, # 2.
Patient # 2 was admitted on 7/17/2013 and received their first dose of Suboxone 7/17/2013. The patient provided their initial urine drug screen on 7/11/2013 The facility did not have documentation of receiving the results back from the CLIA and Department of Health approved laboratory prior to the administration of a narcotic agent until 7/18/2013. This was after the initial dose.
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Plan of Correction
It will remain our policy that urinalysis results be obtained prior to physician review and appointment. Facility director will ensure results are made available to the LPN and patient chart prior to appointments with the physician. LPN will follow up if the UA is not available prior to the appointment. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of patient records, the facility failed to document a complete personal history in four of four records reviewed.
The findings include:
Five client records were reviewed on August 28, 2013. The facility failed to document the client's recreational history in client records # 1, 3, 4, and 5.
This finding was reviewed with the facility director and was not disputed.
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Plan of Correction
New assessment tool to be used no later than 9/23/2013 that specifically asks about leisure activities. Counselors have been instructed prior to then to ask this question in assessment and document accordingly. Facility director will ensure follow through by random chart audits and weekly staff meeting discussions. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and counselor conclusions and impressions in two of four records reviewed.
The findings include:
Five client records were reviewed August 28, 2013. A psychosocial evaluation was reviewed in four client records. The psychosocial evaluations in client records # 4 and 5 failed to include a psychosocial evaluation that included a composite picture of the client's problems and needs to be addressed in treatment, the client's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the counselor's impressions regarding the patient.
The psychosocial evaluations in client record # 4 did not include an evaluation of the client's problems/needs, support systems, and coping mechanisms.
The psychosocial evaluations in client records #5 did not include an evaluation of the client's support systems.
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Plan of Correction
Training on writing clinical based psychosocial evaluations commenced on 8/30/13 with the entire clinical team. Facility director will ensure compliance through random audits of psychosocial evaluation documentation, group clinical supervisions, and individual clinical supervisions to address any issues related to the development of the clinical document.
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