INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. 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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in one of two records.
The findings included:
Two client records were reviewed during the on-site inspection. Client record # 2 contained documentation of contact with the referral program on 3/18/2014. The client record did not contain a consent to release information to the referral program at the time of the review.
This is a repeat deficiency from the on-site complaint investigation from 9/9/2013.
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Plan of Correction
All staff that disseminate client records will be trained on the policies and procedures that a consent to release information must be obtained prior to releasing any and all client information. The training will be completed by the Facility Director and the records for the completion of the training will be maintained in the employee file. As part of the new employee training this policy and procedure will be completed during the orientation period.
To ensure that these policies and procedures will followed, random chart audits of client records will be conducted on a monthly bases. The audits will be completed by the Clinical Supervisor. The results will be maintained in the electronic medical record.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of client records, the facility failed to document a complete initial drug-screening urinalysis prior to the administration of a narcotic agent in one of one record reviewed.
The findings included:
Two client records were reviewed during the on-site inspection. One record was reviewed from the detoxification activity.
Client record # 1 was admitted 3/15/2014. The client record contained documentation of the client being prescribed Suboxone on 3/16/2013 at 1200. The client record did not contain an initial drug-screen urinalysis at the time of the review.
This is a repeat deficiency from the on-site complaint investigation from 9/9/2013.
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Plan of Correction
All medical staff will be trained in the protocol and policies that requires that clients have an initial urinalysis completed prior to the administration of a narcotic agent. The training will address Pyramid Healthcare protocol and policy that all clients that are opiate dependent will receive a urinalysis at the time of admission. Also the training will include the protocol and policies that the results of the urinalysis be placed in the client record as soon as the results are obtained, which is during the admissions process. The training will be completed by the Nurse Manager. The documentation of the training will be maintained in the employee records. To ensure that all new staff are familiar with the protocol and policies it will be a requirement of new employee orientation and maintained in their employee record.
This process will be monitored through monthly chart audits. The Nurse Manger will be responsible for completing the chart monitoring and the audits will be maintained in the electronic medical record.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 include a comprehensive psychosocial evaluation in one of one record.
The findings included:
Two client records were reviewed during the on-site inspection. One client record was from the inpatient rehabilitation activity. Client record # 2 contained a psychosocial evaluation that was a repeat of client reported history and did not include the clinical evaluation of the history.
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Plan of Correction
All clinical staff will be trained in in completing a comprehensive psychosocial evaluation in accordance with DDAP regulations. The training will be completed by the Clinical Supervisor and documented in the employee record. Each new clinical employee will be trained on completing the comprehensive psychosocial evaluation as part of their orientation, this training will be documented and in the employee record. Random Chart audits of all clinical staff will be completed on a monthly basis, which will include reviewing the comprehensive psychosocial evaluation. The Chart Audits will be completed by the clinical supervisor as to the content of the comprehensive psychosocial evaluation, this will ensure that the clinical staff are completing the comprehensive psychosocial evaluation in accordance with DDAP regulations. The chart monitors will be maintained in the electronic medical record. All clinical staff will be trained by 5/20/2014. |