INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on November 18, 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 to be not 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records and a converstaion with facility staff the facility failed to provide documentation of counselor qualifications in personnel record #6.
Employee #6 was hired as a counselor on 2/1/2016. Employee #6 has a Master's Degree in Human Services that did not include a practicum.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Counselor qualification process review was discussed at Regional Operations meeting with facility, regional, administrative, and HR representatives present. To strengthen qualification review process moving forward, in addition to facility and HR review of qualifications, all new candidates will be reviewed by the clinical compliance team prior to on boarding to assist with appropriate titles and qualifications.
Meeting to review this process occurred 12/2/2016.
Employee #6 now has required experience and will remain in her current role. |
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 and a conversation with the facility staff, conducted on 11/18/16, the facility failed to obtain informed and voluntary consent forms in nine client records.
Client #1 was admitted on 9/16/16 and was an active client at the time of the licensing inspection. A consent to release form, dated 9/16/16 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #2 was admitted on 9/5/16 and was an active client at the time of the licensing inspection. A consent to release form, dated 9/6/16 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #3 was admitted on 8/29/16 and was an active client at the time of the licensing inspection. A consent to release form, dated 8/29/16 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #4 was admitted on 10/3/16 and was an active client at the time of the licensing inspection. A consent to release form, dated 10/3/16 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #5 was admitted on 4/7/16 and was discharged 8/19/16. A consent to release form, dated 4/7/16 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #6 was admitted on 2/2/16 and was discharged 6/29/16. A consent to release form, dated 4/28/16 to a treatment provider, did not contain a provision for the consent to be revoked. Additionally, there was no documentation that the client was offered a copy of the consent.
Client #7 was admitted on 2/29/16 and was discharged 6/15/16. A consent to release form, dated 2/29/16 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #8 was admitted on 3/24/16 and was discharged 8/2/16. A consent to form, dated 3/24/16 to a government agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
Client #10 was admitted on 1/19/16 and was discharged 6/6/16. A consent to form, dated 3/1416 to a government agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment."
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
To address areas of concern in this citation the following has occurred organization wide to address this at the facility level effective 11/30/2016.
Statement regarding the inability to revoke criminal justice consents for court mandated clients has been removed from consent forms in ECR system.
Staff reviewed revision to consent forms and client's right to revoke in staff meeting on 11/30/2016.
Clients 1, 2,4 referenced in observations are still enrolled in treatment services and will sign updated consent for any criminal justice involvement. A caseload review of all currently admitted clients by each counselor has been initiated as of 12/21 to sign updated consents for all currently enrolled clients not reviewed in this licensing visit that corrections may apply to during their individual sessions.
No additional actions are needed to support new admits into the program, as the form currently in the chart is corrected as of 11/30/2016 and only administrators have the ability to revise to avoid user error at the facility level.
An all staff training is under development for our mylearningpointe training system to launch in 2017 training year to reinforce for current and new hires.
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715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on a review of the facility's policy and procedure manual on November 7-8, 2016, the facility failed to provide a complete policy and procedure addressing unusual incidents. The facility did not include the following verbiage in the unusual incident policy "inappropriate behavior by a patient causing disruption to the narcotic treatment program" and "incidents with potential for negative community reaction."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To strengthen the unusual incident policy and procedures organization wide our Clinical Compliance officer in collaboration with site based RISK leads will be revise existing policy to address "inappropriate behavior by patient causing disruption to the narcotic treatment team program".
At the facility level, additional review with RISK leads occurred during staff meeting on 11/30/2016 and additional facility incident management training were added to mylearningpointe for staff at OP facility on 12/2/2016. |
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 the review of client records, the facility failed to document a psychosocial evaluation that included the counselor's documented evaluative statement and recommendations based on information gathered in client histories in records, #1, 4, 7 & 9.
Client #1 was admitted on9/16/16 and was an active client at the time of the licensing inspection.
Client #4 was admitted on 10/3/16 and was an active client at the time of the licensing inspection.
Client #7 was admitted on 2/29/16 and was discharged on 6/15/16.
Client #9 was admitted on 12/29/15 and was discharged on 4/7/16.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Facility staff participated in review of audit findings and all staff review of clinical quality standards regarding psychosocial evaluations on 11/30/2016.
Staff also reviewed in group supervision on 11/29/2016.
Clinical supervisor will audit 5 psychosocial evaluations per counselor, per month for the next 3 months to ensure consistency in applying training feedback.
In addition to auditing outlined above, periodic chart audits will continue to occur monthly to ensure deficiency does not re-occur. |