INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated inspection, client records were reviewed on September 29, 2020 and the physical plant inspection was conducted on October 22, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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 a review of four client records on September 29, 2020, the narcotic treatment program failed to verify that the individual has reached 18 years of age. Patient # 14 was admitted on October 21, 2019 and was discharged on March 6, 2020. The program failed to verify that patient # 14 had reached 18 years of age. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
While the program has an intake check list that prompts the staff to verify that individuals have reached 18 years of age to be eligible for admission to the program, we discovered that when clients have been admitted to one of our outpatient treatment programs prior to being admitted to the narcotic treatment program, that the narcotic treatment program intake staff was bypassing the check list because the information had already been gathered at the time of admission to outpatient services. In the case of Patient #14, he was admitted to outpatient services on 10/10/2019 and at that time his ID (driver's license) was viewed and copied into the file.
Our plan of correction is to eliminate the bypassing of ID verification in clients who are admitted to other programs. The intake nurse will verify age of the client, make a copy of ID and document that on the intake checklist prior to admitting the client to narcotic treatment services. The nurse will place a copy of the ID and the checklist into the client chart at the time of admission to the narcotic treatment program regardless of documentation that may have been gathered as part of admission to other agency programs. This procedure will begin on 11/23/2020 and continue ongoing.
Responsible Staff: Nurse
Date of completion: 11/23/2020
To monitor that this is completed, the Program Director will review all new admissions to the narcotic treatment program as part of the weekly staffing and at the time of staffing, review the chart for ID verification. This procedure will begin on 12/3/2020 and continue ongoing.
Responsible Staff: Program Director
Date of Completion: 12/3/2020. |
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 a review of four client records on September 29, 2020, the narcotic treatment program failed to verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data. Patient # 14 was admitted on October 21, 2019 and was discharged on March 6, 2020. The program failed to verify patient # 14's identity including name, address, date of birth, emergency contact and other identifying data. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Review of this citation revealed in cases where clients were already admitted to other agency outpatient programs, the narcotic treatment nurse was relying on the documents gathered by assessment staff for verification, bypassing the admission check list that includes verification of name, address, date of birth, emergency contact and other identifying data.
Beginning 11/23/2020, the narcotic treatment program intake nurse will gather and conduct verification of client identity regardless of admission to other programs. The nurse will gather ID information, copy any verification documents, complete the admission checklist and scan and upload all of these into the client's electronic medical record.
Responsible Party: Nurse
Date of Completion: 11/23/2020 and ongoing.
The nurse will conduct a monthly audit of files for the narcotic treatment program and check for chart compliance including ID verification on 10% of client records each month. This review will be monitored by the Program Director monthly and the results submitted to the agency's Quality Management Team.
Responsible Party: Program Director
Date of Completion: 12/3/2020 and ongoing. |