INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6-7, 2017, 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:
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Plan of Correction
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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.
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Observations
Based on a review of client records on December 6-7, 2017, the facility failed to obtain an informed and voluntary consent in one of eight client records reviewed.
Client #3 was admitted to detoxification treatment on November 6, 2017, transferred to rehabilitation on November 11, 2017, and was still an active client. The client record did not contain documentation of a consent to release information for the funding source, whom they were billing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff will review the need for an informed and voluntary consent from the client for the disclosure of information contained in the client record including consent to release of information for the funding sources in the clinical meeting on 1/4/18. Clinical Supervisor will monitor compliance in this area through bi-weekly documented supervision and completion of monthly open and closed chart audits. A caseload review by each counselor will be initiated as of 1/8/18 to sign updated consents for all currently enrolled clients not reviewed in this licensing visit that corrections may apply during their individual sessions. |
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 patient records on December 6-7, 2017, the facility failed to verify the individual had reached 18 years of age, the individual's identity including name, address, and date of birth in four of five patient records.
Patient #1 was admitted to treatment on 12/3/2017 and was administered 2 mg of Subutex on 12/3/2017 at 7:45 pm. There was no identification or other form of verification documented in the patient record.
Patient #2 was admitted to treatment on 12/4/2017 and was administered 2 mg of Subutex on 12/5/2017 at 9am. There was no identification or other form of verification documented in the patient record.
Patient #3 was admitted to treatment on 11/6/2017 and transferred to maintenance rehabilitation on 11/11/2017. Patient #3 was administered 2 mg of Subutex on 11/7/2017 and is presently on 8/2 mg of Suboxone during maintenance. There was no identification or other form of verification documented in the patient record.
Patient #4 was admitted to treatment on 7/30/2017, transferred to maintenance rehabilitation on 8/4/2017, and discharged successfully on 10/9/2017. Patient #4 was administered 2 mg of Subutex on 7/31/2017 at 10 am and received 8/2 mg of Suboxone while in maintenance. There was no identification or other form of verification documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff will review the policy and process of patient identification in the nursing meeting on 1/11/18.
All clients will have a picture with their full name and dated of admission on MARs for full identification.
Nurse manager will ensure the nurses identify the patient and document through use of checklist and a documented review in the nursing monthly supervision.
Program Director will review the policy and process of patient identification documentation with the intake supervisor and nurse managers in the monthly supervision on 1/10/18
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of client records on December 6-7, 2017, the facility failed to obtain an informed, voluntary, written consent before an agent being administered for detoxification in five of five client records reviewed.
Client #1 was admitted to treatment on 12/3/2017and was still an active client. A consent for buprenorphine treatment was dated 12/3/2017, but was not signed by the client at the time of the inspection.
Client #2 was admitted to treatment on 12/4/2017 and was still an active client. There was no consent for buprenorphine treatment in the client record.
Client #3 was admitted to treatment on 11/6/2017 and transferred to rehabilitation on 11/11/2017. A consent for buprenorphine treatment was dated 11/6/2017, but was not signed by the client at the time of the inspection.
Client #4 was admitted to treatment on 7/30/2017 and transferred to rehabilitation on 8/4/2017 prior to discharge on 10/9/2017. A consent for buprenorphine treatment was dated 7/30/2017, but was not signed by the client at the time of the inspection.
Client #8 was admitted to treatment on 11/30/2017 and discharged 12/5/2017. A consent for buprenorphine treatment was dated 11/30/2017, but was not signed by the client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff will review the policy and process of patient signature on the nursing meeting on 1/11/18.
All clients will sign the necessary consents for any narcotic medication as needed prior to administration
Nurse manager will ensure the nurses confirm that there is a consent prior to administration through use of checklist and review in the documented nursing monthly meeting
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on a review of client records, the facility failed to include laboratory test results for blood work in three of five client records reviewed from the narcotic treatment program.
Client #3 was admitted to detoxification treatment on 11/6/2017 and transferred to rehabilitation on 11/11/2017. There was no documentation for blood work in the client record at the time of inspection.
Client #4 was admitted to detoxification treatment on 7/30/2017, transferred to rehabilitation on 8/4/2017, and discharged from treatment on 10/9/2017. There was no documentation for blood work in the client record at the time of inspection.
Client #8 was admitted to detoxification treatment on 11/30/2017 and discharged on 12/5/2017. There was no documentation for blood work in the client record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff will review the policy and process of lab test result and documentation of any refusals on 1/11/18. The Lab results are reviewed and documented by Nurse Manager and the Physician as needed upon completion. The Nurse Manager will ensure the documentation of all the lab results through chart audits and a monthly documented review with Nurses in the Monthly Nursing supervsion |