INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on (date) 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that all of its staff had the mandatory training in communicable diseases within the required time frames.
Staff Person #5 was hired as a counselor on May 31, 2017, and was required to have 6 hours of HIV/AIDS training, and 4 hours of TB/STD training by May 31, 2018, but at the time of the on-site inspection the facility had no documentation that the staff person received any of the required training.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Clinical Director for the facility will track/monitor completion of staff Communicable Diseases training for all employees. Program Director will ensure that all Department Supervisors monitor their assigned staff for compliance of Communicable Diseases training attendance through supervision. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. Target date for completion is 9/30/2018 |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to ensure that all of its staff had the required annual training.
Staff Person #3, a counselor, was required to have twenty five hours of training in the 2017 training year, but at the time of the on-site inspection, the staff person only had fifteen hours of documented training for the year 2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Clinical Director for the facility will track/monitor completion of staff training hours for all employees. Program Director will ensure that all Department Supervisors monitor their assigned staff for compliance of annual required training attendance through supervision. Human Resource Coordinator to complete quarterly reviews of employee files for facility staff to ensure 100% compliance. Target date for completion is 9/30/2018. |
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
The facility failed to document that it notified patients of involuntary termination from treatment in one of one applicable patient records reviewed.
Patient # 4 was admitted for treatment on May 24, 2018, and involuntarily discharged on July 5, 2018.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Clinical Director will review with clinical staff during group and individual supervision the need to notify a client in writing of the decision to involuntarily terminate the client from treatment at the facility. The written notice will include the reasons for the termination. Clinical Director will monitor compliance in this area through weekly documented supervision and completion of monthly open and closed chart audits. Target date for completion is 09/30/2018. |
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
The facility failed to ensure that it acquired all of the required information prior to admitting patients for narcotic treatment.
The facility did not document the emergency contact information for patients # 3, 8 and 9.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Program Director will review with Intake staff the need to have an emergency contact in the client's chart during supervision to be conducted and documented weekly. Should a client chose not to identify a emergency contact, the intake staff will document this in a memo to chart within the clients file. Program Director will monitor compliance in this area through weekly documented supervision and completion of monthly open and closed chart audits. Target date for completion is 09/30/2018. |
715.14(d) LICENSURE Urine testing
(d) A narcotic treatment program shall ensure that a laboratory that performs the testing required under this section shall be in compliance with applicable Federal requirements, specifically the Clinical Laboratory Improvement Amendments of 1998 (42 U.S.C.A. §§ 201 note, 263 and 263a notes), and State requirements, specifically the Pennsylvania Clinical Laboratory Act (35 P.S. §§ 2151-2165) and Chapter 5 (relating to clinical laboratories).
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Observations
The facility failed to ensure that all of the laboratories performing its urine screen met the requirements to do the screens.
The facility performs an initial dip test urine screen on patients, in addition to sending patient urine samples to a laboratory for testing.
The facility does not have a certificate from the Pennsylvania Department of Health documenting that the facility is in compliance with the Pennsylvania Clinical Laboratory Act (35 P.S. 2151-2165) and Chapter 5 (relating to clinical laboratories).
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Director of Nursing has already completed the application with the State to obtain the certificate to be in compliance with the Pennsylvania Clinical Laboratory Act.
Program Director and Director of Nursing will monitor expiration dates and certifications on a spreadsheet to ensure the facility never operates without the proper certificates on file. This spreadsheet will be reviewed monthly in the monthly nursing meeting.
Dip tests will not be used by the facility until the facility has the proper certificate from the Pennsylvania Department of Health documenting that the facility is in compliance with the Pennsylvania Clinical Laboratory Act (35 P.S. 2151-2165) and Chapter 5 (relating to clinical laboratories). |
715.23(a) LICENSURE Patient records
(a) A narcotic treatment program shall maintain patient records in conformance with 42 CFR 2.16 and 2.22 (relating to security for written records; and notice to patients of Federal confidentiality requirements) and State statutes and regulations. A narcotic treatment program shall maintain a complete file on the premises for each present and former patient of the narcotic treatment program for at least 4 years after the patient has completed treatment or treatment has been terminated. Files shall be updated regularly so that the information is current.
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Observations
The facility failed to document treatment plan updates at least once every 30 days in two of seven patients records reviewed.
The treatment plans for non-hospital residential treatment must be updated at least once every 30 days.
Patient #3 was admitted for non-hospital residential treatment on April 14, 2018, and discharged from non-hospital residential treatment on July 23, 2018. The patient's treatment plan was last updated on June 8, 2018.
Patient #6 was admitted for non-hospital residential treatment on March 30, 2018, and discharged from non-hospital residential treatment on June 4, 2018. The patient's individualized treatment plan was dated April 4, 2018, but there was no documented update until May 23, 2018.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The clinical staff will ensure that treatment plans will be reviewed and updated at least every 30 days. If length of treatment stay is less than 30 days, the treatment plan, review and update will occur at least every 15 days and be documented accordingly in each of the clients' records. The Clinical Director will review these documentation requirements with the clinical staff and monitor for compliance through weekly documented supervision and by completing monthly open and closed chart audits. Target for completion date is 09/30/2018. |