INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 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. Waynesboro 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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709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
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Observations
During a Project Wide review of Policy and Procedures, the facilities 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 facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual will be updated by the Policy and procedure committee to include sex and marital status in section 709.30. Chief Compliance Officer will ensure completion of policy by Sept 1, 2019. The program director will be responsible to ensure that the new policy is shared with all staff by Sept 15, 2019. |
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
During a licensing inspection conducted on August 16, 2019, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client records # 1, 2, 3, 4, 5, and 6.Client # 1 was admitted on February 25, 2019 and was still active at the time of the inspection. An informed and voluntary consent form to an insurance company allowed for the disclosure of admission, continued stay, discharge communication and continuing in treatment. Client # 2 was admitted on January 3, 2019 and was still active at the time of the inspection. An informed and voluntary consent form to one insurance company allowed for the disclosure of admission, continued stay, discharge communication and continuing in treatment. An informed and voluntary consent form to a second insurance company allowed for the disclosure of admission, continued stay, discharge communication and continuing in treatment. Client # 3 was admitted on June 26,2019 and was still active at the time of the inspection. An informed and voluntary consent form to an insurance company allowed for the disclosure of admission, continued stay, discharge communication and continuing in treatment.Client # 4 was admitted on October 22, 2018 and was discharged on January 28, 2019. An informed and voluntary consent form to an insurance company allowed for the disclosure of admission, continued stay, discharge communication and continuing in treatment.Client # 5 was admitted on March 7, 2019 and was discharged on April 22, 2019. An informed and voluntary consent form to an insurance company allowed for the disclosure of admission, continued stay, discharge communication and continuing in treatment.Client # 6 was admitted on September 19, 2018 and was discharged on May 14, 2019. An informed and voluntary consent form to a funding agency allowed for the disclosure of admission, continued stay, discharge communication and continuing in treatment.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will create a reference document for staff indicating proper documentation of releases when completing releases of information to funders. Staff will be retrained on this topic on 9/12/2019, and documented via sign in sheet and staff meeting minutes. The Clinical Supervisor will audit charts for this standard on a monthly basis. Retraining and correction to the documentation will occur with staff failing to meet this standard. In addition the Executive Director will submit a request to change the funding entity ROI form in the electronic medical record to not allow for consent beyond the limits of 4 Pa. Code 255.5 (b). |
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
During a licensing inspection conducted on August 16, 2019, the facility failed to document the medical history in client # 6's record. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
: The Executive Director did review with the Clinical Supervisor that all sections must be reviewed and verified as complete in the Level of Care Assessment document before it is approved on 9/4/2019. This will be documented in the staff supervision log. Staff will be retrained on this to ensure these sections are not missed on 9/12/2019. This will be documented in the Staff Meeting minutes. Staff retraining will occur as needed based on performance. Retraining will be documented in supervision logs. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
During a licensing inspection conducted on August 16, 2019, the facility failed to document the drug or alcohol history, or both in client # 6's record. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director did review with the Clinical Supervisor that all sections must be reviewed and verified as complete in the Level of Care Assessment document before it is approved on 9/4/2019. This will be documented in the staff supervision log. Staff will be retrained on this to ensure these sections are not missed on 9/12/2019. This will be documented in the Staff Meeting minutes. Staff retraining will occur as needed based on performance. Retraining will be documented in supervision logs. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
During a licensing inspection conducted on August 16, 2019, the facility failed to document the personal history in client # 6's record. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director did review with the Clinical Supervisor that all sections must be reviewed and verified as complete in the Level of Care Assessment document before it is approved on 9/4/2019. This will be documented in the staff supervision log. Staff will be retrained on this to ensure these sections are not missed on 9/12/2019. This will be documented in the Staff Meeting minutes. Staff retraining will occur as needed based on performance. Retraining will be documented in supervision logs. |
709.93(a)(6) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(6) Individual treatment and rehabilitation plan.
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Observations
During a licensing inspection conducted on August 16, 2019, the project failed to provide a complete client record in three out of seven records reviewed. Client records for clients #4, #5, and #6 failed to include individualized (comprehensive) treatment and rehabilitation plans.Client # 4 was admitted on October 22, 2018 and discharged from the project on January 28, 2019. An initial treatment and rehabilitation plan was created on October 22, 2018. A comprehensive treatment and rehabilitation plan was not developed prior to the client's discharge on January 28, 2019.Client # 5 was admitted on March 7, 2019 and discharged from the project on April 22, 2019. An initial treatment and rehabilitation plan was developed on March 7, 2019. A comprehensive treatment and rehabilitation plan was not developed prior to the client's discharge on April 22, 2019. Client # 6 was admitted on February 21, 2019 and discharged from the project on June 19, 2019. There was no documentation of any treatment and rehabilitation plans being completed with client #6. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will review with staff timely discharge standards for inactive clients. This will be done on 9/13/2019 and documented in staff meeting minutes. In addition, caseload reports and expiring treatment plan reports will be reviewed with clinical staff during bi-weekly supervision to ensure that these standards are being followed. This will be documented in supervision logs with staff. Staff retraining will occur as needed based on performance. Retraining will be documented in supervision logs. |