INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone & buprenorphine monitoring inspection conducted on June 20, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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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
Based one of eight applicable employee personnel records reviewed, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year January-December 2022 in employee record #8
Employee # 8 was hired as a counselor on March 9 2020, and was still in this position at the time of the inspection. After a review of employee #8's personnel record, there was only 15.75 training hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will run a report in RELIAS, our internal training system, to check clinical staff training hours every 60 days. This was implemented starting July 1, 2023.
Clinical supervisor, lead counselor, and executive director will review training hours with staff during weekly treatment team meetings.
Clinical supervisor and lead counselor will address clinical staff individually during monthly supervision to help monitor training hours throughout the calendar year to ensure that all counselors meet the training hour requirement of 25 hours annually.
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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
Based on three of eight applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty or 120 days if client is stable in client record #3, #7 and #8
Client # 3 was admitted on November 14, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on February 10, 2023. A treatment and rehabilitation plan update was due no later than April 10, 2023. There was no documentation of a treatment plan update in the client record.
Client # 7 was admitted on December 9, 2020 and discharged on November 22, 2022. A treatment and rehabilitation plan was developed on June 30, 2022. A treatment and rehabilitation plan update was due no later than August 30, 2022. A treatment and rehabilitation plan update did not occur until September 19, 2022.
Client # 8 was admitted on March 27 2014 and discharged on November 22, 2022. A treatment and rehabilitation plan was developed on November 18, 2022. A treatment and rehabilitation plan update was due no later than March 18, 2023. A treatment and rehabilitation plan update did not occur until April 5, 2023.
These findings were reviewed with facility staff during the licensing process
This is a repeat citation from the August 17, 2022 licensing inspection.
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Plan of Correction
All counselors will be required to keep a case tracker of their clients that specifically track treatment plan dates of completion and next due date. This will be updated on a daily basis. Case management trackers will be reviewed for treatment plan tracking in staff meeting on 7/20/2023.
Clinical supervisor and/or lead counselor will review individualized case management trackers with counselors at the time of monthly individual sessions. This will allow us to ensure that treatment plans are reviewed and updated within the appropriate clinical intervals (60 days or 120 days as applicable).
Clinical supervisor will utilize counselor alerts (within the EMR system) to remind counselors at least 15 days ahead of time for treatment plans that need to reviewed and completed. This will ensure that counselors have 15 days to meet with clients and treatment plans are reviewed and updated prior to their due date.
Pyramid Healthcare's regional quality team will be auditing for treatment plan compliance. Regional quality team will then meet with leadership team monthly to review their findings.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of three out of eight client records, the facility failed to provide treatment services based on the individual treatment plan in client records #3, #6 and #7.
Client #3 was admitted on November 14, 2022 and was still active at the time of the inspection. The comprehensive treatment plan dated February 10, 2023 indicated one group and one individual session monthly. The client's record of service indicated that the client received no group session as of the date of the inspection.
Client#6 was admitted September 8, 2022 and was discharged May 2, 2023. The comprehensive treatment plan dated November 30, 2022 indicated one group session monthly. The client's record of service indicated that the client received no group sessions.
Client#7 was admitted on December 9, 2020 and was discharged November 22, 2022. The treatment plan dated February 1, 2022 indicated one group monthly. The client's record indicated they did not receive any group sessions.
These findings were discussed with facility staff during the inspection process
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Plan of Correction
All counselors will be required to keep a case tracker of clients on their caseload that specifically tracks group enrollment and attendance. The case tracker will be updated on a weekly basis. Case trackers will be reviewed for group attendance tracking in staff meeting on 7/20/2023.
Clinical Supervisor and lead counselor will audit 15% of client charts prior to monthly supervision with counselors. Leadership team will review that treatment services are scheduled and occurring based on the individual treatment plan in the client records. This audit will be done by comparing the treatment plan to the service history report to ensure clients are being scheduled for the correct treatment services. Leadership staff will check case trackers every two weeks for group attendance monitoring.
During monthly supervision, clinical supervisor and lead counselor will review with individual counseling staff their findings. If clients are scheduled, but not engaging in treatment services for monthly group sessions then client's treatment plan will be modified.
Pyramid Healthcare's regional quality team will be auditing for group attendance that is in accordance with individualized treatment plans. Regional quality team will then meet with leadership team monthly to review their findings.
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