INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 27, 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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715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on the review of patient records, the facility failed to document verification that the individual has reached 18 years of age in one of five patient records reviewed.Five patient records were reviewed on September 27, 2017 for documentation of verification that the individual has reached 18 years of age. Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. Patient record #3 was admitted on March 23, 2017 and was discharged on July 27, 2017. The initial dose of Suboxone was given to the patient on April 5, 2017. The facility failed to document verification that the individual has reached 18 years of age prior to administration of Suboxone.The findings were reviewed with the facility during the licensing process.
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Plan of Correction
All staff were re-educated on the importance of obtaining a photo ID from patients to verify patient's date of birth. Any patients requesting admission into the MAT program must provide Administrative Assistant with photo ID. The Nurse then verifies retention of the photo ID before scheduling client for induction. This new process has ensured that all clients currently in program have a photo ID on file to date.
Retention of client's photo ID has also been added to monthly medical chart audits by Nurse and Clinical Supervisor to ensure all MAT patients have reached 18 years of age.
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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 client records on September 27, 2017, the facility failed to document verification of the individual's identity, including name, address, date of birth and other identifying data, in one of five patient records prior to administration of Suboxone.Client #3 was admitted to treatment on March 23,2017 and discharged July 27, 2017. The initial dose of Suboxone was administered on April 5, 2017. The client record did not include documentation required to verify the individual's identity.The findings were reviewed with the director and were not disputed.
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Plan of Correction
All staff were re-educated on the importance of obtaining a photo ID from patients to verify patient's identity including name, address, date of birth, emergency contact and other identifying data. Any patients requesting admission into the MAT program must provide Administrative Assistant with photo ID. The Nurse then verifies retention of the photo ID before scheduling client for induction. This new process has ensured that all clients currently in program have a photo ID on file to date.
Retention of client's photo ID has also been added to monthly medical chart audits by Nurse and Clinical Supervisor to ensure all MAT patients have had their identity verified.
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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
Based on a review of client records, the facility failed to complete sixty day treatment plan updates in three of six client records reviewed.Nine client records were reviewed on September 27, 2017. Sixty day treatment plan updates were required in six client records. The facility did not document treatment plan updates every sixty days in client records # 1, 3, and 4.Client #1 was admitted on January 30, 2017 and the comprehensive treatment plan was completed on July 28, 2017. A treatment plan update was due by April 28, 2017 but was completed on 5/3/2017.Client #3 was admitted on March 23, 2017 and the comprehensive treatment plan was also completed on March 23, 2017. A treatment plan update was due by May 23, 2017 but was completed on May 26, 2017.Client #4 was admitted on July 5, 2016 and the most recent treatment plan updates were February 5, 2017, April 5, 2017, and July 9, 2017.The findings were reviewed with the facility 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 in new EMR to monitor treatment plan compliance. Clinical Supervisor has reviewed report for all active clients to date and has resolved all outstanding tx. plan updates. Ongoing, the Clinical supervisor will review report weekly with clinical staff to maintain compliance. Complete compliance as of 11/10/2017. |