INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 5, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Chambersburg was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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
Based on the review of personnel records, personnel record #4 did not contain documentation of tuberculosis, sexually transmitted disease (TB/STD) training within the required time frame. Employee #4 was hired July 6, 2015 as a counselor and was still in that position as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 will have completed the training no later than February 1, 2017. Director will ensure this occurs by scheduling the training with the staff and ensuring follow through. Director will ensure this does not occur again by having support staff schedule the required HIV/AIDS training within the first year of hire and monitor for ongoing compliance. In addition, training requirements will be reviewed monthly with staff during supervision. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The written fire drill records dated August 30, 2016, July 27, 2016, June 30, 2016, May 26, 2016, April 22, 2016, February 29, 2016, January 28, 2016, December 22, 2015, November 25, 2015 and October 22, 2015 did not indicate what exit route was used, if there were problems encountered or whether the fire alarm or smoke detector was operative. They also did not indicate if a fire alarm or smoke detector was set off during each fire drill. Additionally, there was no documentation that an unannounced fire drill was conducted in March 2016.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The proper form documenting the items listed below was implemented immediately after survey.
Exit route used
If there were problems encountered or whether the fire alarm or smoke detector was operative
Indicate if alternate exit routes were used
If a fire alarm or smoke detector was set off during each fire drill.
Program Director will ensure that monthly fire drills are accurately documented on this form. In addition, a fire drill report was created to monitor monthly compliance. This form/process was utilized for October 2016 fire drill.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Eleven out of twelve client records were missing verification that a copy of the consent was offered to the client. Client #1- Consent to Probation, dated February 25, 2016 did not have documentation that the client was offered a copy of the consent. Client #2- Consent to a Treatment Provider, dated January 12, 2016, did not have documentation that the client was offered a copy of the consent. Client #3-Consent to Probation, dated June 7, 2016 did not have documentation that the client was offered a copy of the consent. Client #4- Consents to a Treatment Provider, dated May 26, 2016, a Primary Care Physician, dated May 10, 2016 and an additional Treatment Provider, dated May 10, 2016 did not have documentation that the client was offered a copy of the consent. Client #6- Consent to Probation, dated July 12, 2016 did not have documentation that the client was offered a copy of the consent. Client #7- Consent to Probation, dated January 14, 2016 did not have documentation that the client was offered a copy of the consent. Client #8-Consents to two Probation Offices, both dated May 2, 2016 did not have documentation that the client was offered a copy of the consent. Client #9-Consents to Probation and a Primary Care Physician both dated December 15, 2015 did not have documentation that the client was offered a copy of the consent. Client #10-Consents to two Doctor's Offices, dated August 4, 2015 and February 23, 2016, and an outside agency dated September 8, 2016 did not have documentation that the client was offered a copy of the consent. Client #11- Consents to Probation dated February 29, 2016, and the County Jail dated April 25, 2016 did not have documentation that the client was offered a copy of the consent. Client #12- Consents to Probation, dated July 21, 2016 did not have documentation that the client was offered a copy of the consent. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Coordinator is responsible for updating this form in EMR. EMR system was updated as of 11/30. The 10 charts sited now have the completed consent that documents if a copy was offered. All remaining active clients will have new consents completed in their charts by 12/15. All consents now document that an individual has been offered a copy. In addition, a new EMR will begin to be implemented in January 2017. The VP of Clinical Services will ensure that the new system allows for verification that a client was offered a copy of their consent. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
The project's Unusual Incident reporting policy did not include policies and procedures to respond to the use of illicit drugs on the premises, an event at the facility requiring the presence of police, fire or ambulance personnel and an Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual Incident Policy has been revised by the Vice President of Clinical Services. It now includes policies and procedures to respond to the use of illicit drugs on the premises, an event at the facility requiring the presence of police, fire or ambulance personnel and an Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
This new policy was distributed to all programs and staff as of 11/1/2016. A copy of the new policy was faxed to Department of Drug & Alcohol Programs on 12/2/2016.
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715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of client records, client record #2, who was admitted on January 12, 2016, did not have documentation by the narcotic treatment physician of current dependency and evidence of a 1 year history of addiction at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/18/16, Physician was educated on the importance of accurately documenting an individual's evidence of dependency for a 1 year. LPN will review documentation in EMR weekly to verify that Physician has completed proper documentation. Program Director will conduct random monthly chart audits to confirm compliance. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of client records, client records #2, #4, and #9 did not have documentation that each female patient was fully informed of the possible risk to her or her unborn child as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The nurse will develop a patient education form that documents the possible risk to her or her unborn child in regards to Suboxone. This form will be developed by 12/1/16. Nurse will review education form with all current females in MAT program and obtain signature by 12/30/16. All new female clients entering into program will be educated as a part of their induction appointment as of 12/1/16.
The Program Director will ensure that the patient education form is properly being utilized via random monthly chart audits. |
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
Twelve client records were reviewed on October 5, 2016 for treatment and rehabilitation services. Client #7-The comprehensive treatment plan was completed on February 17, 2016, and an update was due on April 17, 2016 but was not completed until May 2, 2016. Client #9- The comprehensive treatment plan was completed on December 30, 2015, and an update was due on February 20, 2016, but was not completed until April 7, 2016. Client #10- A treatment plan update was due on March 20, 2016, but was not completed until April 4, 2016. An additional treatment plan update was due on June 4, 2016 and was not completed until June 27, 2016. Client #11-A treatment plan update was due on July 4, 2016, but was not completed until July 18, 2016. An additional treatment plan update was due on September 18, 2016 but was not completed until September 22, 2016. These findings were reviewed with facility staff 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 to monitor treatment plan compliance.
Complete compliance will be by 12/1/16. |