INITIAL COMMENTS
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This report is a result of an unannounced inspection conducted on May 23, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare York Pharmacotherapy Services 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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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a client record review, the facility failed to complete a psychosocial evaluation in one of one client record.
The findings include:
One client record was reviewed on-site. Client #1 was admitted to outpatient treatment on February 26, 2013, and discharged on April 29, 2013. A psychosocial evaluation was due to be completed by March 26, 2013. At the time of the review, a psychosocial evaluation had not been documented in client record #1
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
Program Director met with assigned counselor on June 27, 2013 and reviewed timeframes for the completion of psychosocial evaluations. Evidence of meeting was documented in staff file.
Missing documents were completed by counselor and filed in client chart.
Program Director will conduct monthly random chart audits to ensure continued compliance.
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709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a client record review, the facility failed to document a discharge summary within one week of discharge in one of one client record.
The findings include:
One client record was reviewed on-site. Client #1 was admitted to outpatient treatment on February 26, 2013, and discharged on April 29, 2013. A discharge summary is due within one week of discharge. At the time of review, a discharge summary had not been documented in client record #1.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
Program Director met with assigned counselor on June 27, 2013 and reviewed timeframes for the completion of discharge summaries. Evidence of meeting was documented in staff file.
Missing documents were completed by counselor and filed in client chart.
Program Director will conduct monthly random chart audits to ensure continued compliance.
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