INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18 through 19, 2010 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 and a plan of correction is due on November 23, 2010.
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Plan of Correction
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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 a review of client records and the facility's policies and procedures, the facility failed to document a treatment plan update in one of one client record.
The findings include:
Facility policy states treatment plans will be reviewed and updated every 60 days for outpatient clients.
One client record requiring treatment plan updates was reviewed on October 18, 2010. The facility did not document a treatment plan update at least every sixty days in outpatient client record # 12.
Client #12 was admitted on November 17, 2009 and discharged on August 13, 2010; the treatment plan was documented on January 19, 2010. The comprehensive treatment plan was updated on March 19, 2010. Treatment plan updates were due by May 19, 2010 and July 19, 2010 but had not been completed.
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Plan of Correction
In a documented meeting, the policy was reviewed in supervision with the staff in question on 10-25-10 for retraining purposes.
Compliance will be reviewed during monthly chart monitoring by the director and weekly peer reviews by the other clinicians.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of the facility's policies and procedures and outpatient client records, the facility failed to document an aftercare plan that included goals with time frames, support services, and the contact person in one of one client record reviewed.
The findings include:
On October 18, 2010 one outpatient client record was reviewed for documentation of an aftercare plan. The facility failed to document an aftercare plan that included goals with time frames, support services, and a contact person in the record reviewed.
Client #9 was admitted on July 15, 2010 and discharged on September 2, 2010. The aftercare plan was completed on September 2, 2010. The goals listed in the aftercare plan did not specify time frames for the goals to be completed. Furthermore, the aftercare plan did not include support services or the contact person for reentry.
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Plan of Correction
In a documented meeting, the policy was reviewed in supervision with the staff in question on 10-25-10 for retraining purposes.
The aftercare form will be adjusted to include time frames, support services, and contact person to prompt the clinicians - to be completed by 11-30-10.
This will be monitored on a monthly basis by the director during closed chart reviews.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of the facility's policies and procedures and client records, the facility failed to document follow-ups in four of four client records.
The findings include:
The facility's policy states that follow ups will be conducted within 7 days of discharge via telephone call. The results of the follow-up are to be documented and become a part of the client's permanent record.
On October 18, 2010 four outpatient client records were reviewed for follow-up documentation. The facility did not document the dates in which follow-ups had been conducted in client records #9, 10, 11, and 12.
This was confirmed by the facility director.
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Plan of Correction
The policy was reviewed in supervision with the staff in question on 10-25-10 for retraining purposes.
This will be monitored on a monthly basis by the director during closed chart reviews.
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on an interview with the facility director and a review of facility staff CPR documentation, the facility failed to ensure that a sufficient number of staff persons trained in CPR skills are present during the project's hours of operation.
The findings include:
On October 18, 2010 the facility presented the Staffing Requirement Facility Summary Report to the licensing specialist and there was not a current CPR certification card attached, for employee #4. The referenced employee conducts evening group sessions on Tuesdays and Thursday, 5:30 pm-7 pm.
An interview with the facility director confirmed that there is no other CPR certified employee present with employee #4 while the evening groups are being conducted.
The facility failed to provide verification of staff trained in CPR skills during their hours of operation, Tuesday and Thursday, 5:30-7:00 pm.
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Plan of Correction
The staff needing CPR training was recertified in CPR on 10-20-10.
In a documented meeting, the policy was reviewed in supervision with the staff in question on 10-25-10 for retraining purposes.
Training status for each staff member will be reviewed in staff meeting on a quarterly basis to ensure all staff are meeting training deadlines. This will be facilitated and monitored by the program director.
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