INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2019 through September 13, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection conducted on September 13, 2019, the facility failed to ensure the safety and well-being of clients, staff, and visitors through maintaining all structures and fences on the grounds of the facility so as to be free from any danger to health and safety.The 2nd floor nurses station had a hole in the ceiling.The phone jack in the 2nd floor hallway was uncovered and exposing wires.The vent cover in room 249 was broken.The vent cover in room 219 was broken.The heater in room 227 was missing a side panel, exposing the wires.The heater in room 305 was missing a side panel, exposing the wires.The ceiling in the 3rd floor stairwell is coming down; pieces of ceiling were observed to be on the floor.This is a repeat citation from May 10, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 11-1-19, all maintenance deficiencies will be corrected.
Vent covers in rooms 249, 219 along with heaters in 227 and 305 have been corrected since 9-18-19. All staff will fill out maintenance requests if any facility staff finds an item that is in need of fixing. Maintenance checks the maintenance log daily to see what needs fixed and will fix it accordingly. Maintenance and house keeping will check rooms weekly to ensure all rooms are kept in adequate form.
By 11-1-19, the ceiling in the 2nd floor nursing station and 3rd floor stairwell will be fixed.
Maintenance will make rounds weekly through the building and will fix any areas that are in need of attention. Staff will continue to utilize the maintenance request book.
Executive Director will work with Maintenance Supervisor to ensure weekly walk throughs are being carried out. |
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 the review of client records, the project failed to document an informed and voluntary consent to disclose information in 1 out of 14 client records reviewed.Client #5 was admitted on November 23, 2018 and discharged on November 26, 2018. The project failed to document an informed and voluntary consent to disclose information to the client's funding source.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Effective November 1, 2019, Intake Supervisor will be completing bi weekly chart audits to ensure all intake paperwork, consents, assessments and intake paperwork are completed and will document the findings. If Intake supervisor is not available, Intake Coordinator will complete and document the audits.
If any staff are continuously deficient in paperwork, they will review this in supervision with the Intake Supervisor. Findings will be reviewed with intake assessors so they are able to complete any missing paperwork. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b). With the written consent of a client, the project may only release to government officials and funding sources: (1) whether the client is or is not in treatment; (2) the prognosis of the client; (3) the nature of the project; (4) a brief description of the progress of the client; and (5) a short statement as to whether the client has relapsed in drug, or alcohol abuse and the frequency of such relapse. Client #12 was admitted on July 30, 2019 and was discharged on August 13, 2019. In client #12's record were three disclosures of information forms, one for the funding source and two for government agencies, permitting the release of progress notes, medication records, psychological assessments, patient history, psychiatric evaluations and physical exams.This is a repeat citation from August 9, 2018.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Executive Director will work with our Clinical Coordinator to schedule a training on accurate completion of consents. This training will take place by 11-1-19 and will be with all intake and Clinical Staff who are completing consents. This training will have a sign in sheet to ensure all staff have received re education on proper completion of consents. Any staff who are found to be filling them out incorrectly will be provided additional supervision and training. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
During a Project wide review of Policy and Procedures, the project ' s Client Rights policy was missing - sex and marital status in 709.30 (2), and Reasons for removing sections shall be documented in the record in 709.30 (3). These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The new form to be added to Carelogic for all programs by September 1, 2019. Program Director will ensure all staff are educated on the new form by September 15, 2019. Counselors will review their current caseloads to see when the clients came in to treatment. Any clients who came into treatment prior to the September 1, 2019 form change will have the new information reviewed with them by their counselor in individual sessions if they are still in treatment. This will be documented in an individual note. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of 14 client records, the project failed to notify the client, in writing, of the project ' s decision to involuntarily terminate the client in three applicable records reviewed.Client #5 was admitted on November 23, 2018 and involuntarily terminated on November 26, 2019.Client #12 was admitted on July 30, 2019 and involuntarily terminated on August 13, 2019.Client # 14 was admitted on December 4, 2018 and involuntarily terminated on January 17, 2019. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Executive Director will meet with Clinical Supervisors, and Detox Supervisor by 10-16-19 to discuss the Involuntary termination form and ensure completion. Clinical Supervisors will review this form with their Clinical Team in the Clinical Meeting by 10-22-19. Clinical Supervisors will ensure this is being completed during monthly chart audits. Clinical Supervisors will review any deficiencies with the counselors during bi weekly supervision.
Detox Manger will review this form with his detox specialist to ensure this is being completed with detox staff. Detox Manager will review charts monthly to ensure this form is getting completed. Detox Manager will meet with his staff bi weekly to review deficiencies and correct them during supervision. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the project's unusual incidents log, it was determined that the project did not file a written unusual incident report to the Department following unusual incidents involving events at the project requiring the presence of policy, fire or ambulance personnel.An unusual incident occurring on August 20, 2019, requiring the presence of an ambulance, was not reported to the Department.An unusual incident occurring on August 15, 2019, requiring the presence of an ambulance, was not reported to the Department.An unusual incident occurring on July 23, 2019, requiring the presence of an ambulance, was not reported to the Department.An unusual incident occurring on August 22, 2019, requiring the presence of an ambulance, was not reported to the Department.An unusual incident occurring on August 23, 2019, requiring the presence of an ambulance, was not reported to the Department.An unusual incident occurring on August 26, 2019, requiring the presence of an ambulance, was not reported to the Department.An unusual incident occurring on July 9, 2019, requiring the presence of an ambulance, was not reported to the Department.Three separate unusual incidents occurring on July 25, 2019, requiring the presence of an ambulance, were not reported to the Department.An unusual incident occurring on April 14, 2019, requiring the presence of an ambulance, was not reported to the Department.An unusual incident occurring on March 22, 2019, requiring the presence of law enforcement, was not reported to the Department.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Executive Director will meet with the Nurse who regularly completes the Unusual Incidents to ensure that she is including the fax confirmation with the unusual incidents when she gives a copy to the ED. ED will monitor incidents weekly to ensure incident reports are turned in, including the fax confirmation, and any report that does not have the fax confirmation will be re faxed. ED will meet with the nurse by 10-25-19. There is one Nurse who currently is in charge of completing all unusual incident reports, and she will meet weekly with the ED to ensure this task is completed correctly. In this staff's absence, the ED will meet with the Nurse Manage, who will ensure completion, and ompliance. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of seven narcotic detoxification records, it was determined that the program failed to document an emergency contact for Client # 5.This is a repeat citation from August 9, 2018.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Executive Director will meet with the Intake staff, Intake Supervisor and DON and document the meeting in which we will review that any staff completing an intake should make every attempt to obtain an emergency contact, and if a client declines to list one it must be documented in the chart. This meeting will take place by 11-1-19. If a client declines to list an emergency contact, a memo to chart will be entered by nursing/intake staff. Once a client meets with a detox specialist/counselor, they will also try to obtain an emergency contact from them and document if they accept or decline. |
715.24(4)(iii) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(4) Minimum requirements for short-term narcotic detoxification treatment are as follows:
(iii) The narcotic treatment program shall develop a treatment plan. The patient's counselor shall monitor the patient's progress toward the goal of short-term narcotic detoxification and possible drug-free treatment referral.
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Observations
Based on the review of seven narcotic detoxification records, it was determined that the program failed to develop treatment plans for four clients reviewed.Client #4 was admitted December 8, 2018 and discharged December 13, 2018. There was no documentation that a treatment plan had been developed for the client. Client # 5 was admitted November 23, 2018 and discharged on November 26, 2018. There was no documentation that a treatment plan had been developed for the client. Client #6 was admitted on May 7, 2019 and discharged on May 11, 2019. There was no documentation that a treatment plan had been developed for the client. Client # 7 was admitted on November 16, 2018 and discharged on November 21, 2019. There was no documentation that a treatment plan had been developed for the client. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Executive Director will meet with Detox Manager and Intake Nursing Staff by 10-25-19 to review detox treatment plans and how to effectively write them, along with the time frames for completing this documentation. Detox Manager will do bi weekly chart audits to ensure all treatment plans are being completed upon intake. Detox Manager will review these findings with Executive Director, and if any staff are deficient, this will be discussed with staff during formal supervision and documented. |