INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4, 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.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The written fire drill records for the period of October 2015 through August 2016 did not indicate what exit route was used, if there were problems encountered or whether the fire alarm or smoke detector was operative. Additionally, the logs did not indicate that alternate exit routes were used, as well as if a fire alarm or smoke detector was set off during each fire drill. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The proper form documenting the items listed below was implemented immediately after survey.
Exit route used
If there were problems encountered or whether the fire alarm or smoke detector was operative
Indicate if alternate exit routes were used
If a fire alarm or smoke detector was set off during each fire drill.
Program Director will ensure that monthly fire drills are accurately documented on this form. This form was utilized for October fire drill. |
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
Based on a review of client records, it was observed in client record #4 that the facility released patient identifying information on July 29, 2016 to a funding source and failed to obtain an informed and voluntary consent prior to the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director discussed confidentiality and releases of information with all administrative and clinical staff on 10/13/14 during a staff meeting. All staff were re-trained on the importance of obtaining consent prior to releasing information to anyone. Director will ensure compliance of confidentiality by discussing in weekly staff meetings, addressing any concerns with staff, and by completing random chart audits monthly. |
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
Based on a review of client records, client records 1-10 were missing verification that a copy of the consent was offered to the client. Client #1- Consent to Probation, dated May 24, 2016 did not have documentation that the client was offered a copy of the consent. Client #2- Consents to a Primary Care Physician and a Probation Officer, both dated February 1, 2016, did not have documentation that the client was offered a copy of the consent. Client #3-Consent to Probation, dated December 21, 2015 did not have documentation that the client was offered a copy of the consent. Client #4- - Consents to a Primary Care Physician and Probation, both dated March 22, 2016, did not have documentation that the client was offered a copy of the consent. Client #5- Consent to Probation, dated May 10, 2016 did not have documentation that the client was offered a copy of the consent. Client #6- Consents to a Treatment Provider, Primary Care Physician, Probation, and Insurance Company, all dated November 12, 2015, did not have documentation that the client was offered a copy of the consent. Client #7- Consent to a Probation Officer, dated April 21, 2016 did not have documentation that the client was offered a copy of the consent. Client #8- Consent to a Primary Care Physician, dated June 29, 2016 did not have documentation that the client was offered a copy of the consent. Client #9- Consents to a Treatment Provider, dated September 12, 2016, a Probation, dated September 6, 2016, a Funding Source, dated June 7, 2016 and another Treatment Provider, dated May 4, 2016 did not have documentation that the client was offered a copy of the consent. Client #10- Consents to a Primary Care Physician and Probation, both dated March 3, 2016, did not have documentation that the client was offered a copy of the consent. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Coordinator is responsible for updating this form in EMR. EMR system was updated as of 11/30. The 10 charts sited now have the completed consent that documents if a copy was offered. All remaining active clients will have new consents completed in their charts by 12/15. All consents now document that an individual has been offered a copy. In addition, a new EMR will begin to be implemented in January 2017. The VP of Clinical Services will ensure that the new system allows for verification that a client was offered a copy of their consent. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
The project's Unusual Incident reporting policy did not include policies and procedures to respond to the use of illicit drugs on the premises, an event at the facility requiring the presence of police, fire or ambulance personnel and an Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual Incident Policy has been revised by the Vice President of Clinical Services. It now includes policies and procedures to respond to the use of illicit drugs on the premises, an event at the facility requiring the presence of police, fire or ambulance personnel and an Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
This new policy was distributed to all programs and staff as of 11/1/2016. A copy of the new policy was faxed to The Department of Drug & Alcohol Programs on 12/2/2016. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Ten client records were reviewed on October 4, 2016 for treatment and rehabilitation services. Client #3- A treatment plan update was due no later that April 25, 2016 and was not completed at the time of the inspection. Client #7-The comprehensive treatment plan was completed on April 28, 2016, and an update was due June 28, 2016 but was not completed until August 4, 2016. Client #10- The comprehensive treatment plan was completed on March 9, 2016 and an update was due on May 9, 2016 but was not completed until June 15, 2016. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corporate Clinical Coordinator trained staff on treatment plan update completion. Program Director has discussed this issue in several staff meetings to date. This will be monitored through monthly open and closed chart monitors. In addition, Program Director has developed a specialized report to monitor treatment plan compliance. Complete compliance will be by 12/1/16. |