INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Rehab Management Inc. dba Pyramid York Outpatient 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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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial hospitalization records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of two client records reviewed.
Client #6 was admitted on November 22, 2024 and was discharged on January 3, 2025. A treatment plan was completed on November 27, 2024 and the next update was due no later than December 27, 2024; however, it was not completed until December 31, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor to provide retraining to PHP clinical staff around treatment plan expectations to include timeliness. Completed 1/15/25.
Program leadership will monitor timely treatment plan completion through internal tracking system which Clinical Supervisor will address during clinical and individual supervisions. Currently implemented as of 1/15/25 and will continue to monitor ongoing.
Executive Director will monitor treatment plan completion through reporting system and review with Clinical Supervisor biweekly. Plan implemented 1/15/25. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of outpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in one out of one applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.
Client #9 was admitted on September 30, 2024 and was still active at the time of the inspection. A case consultation was due no later than December 30, 2024; however, none was completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor to meet with clinical staff at upcoming supervision to provide retraining on Case Consult completion and timeliness. Case consults will now be completed during clinical supervision sessions. Retraining scheduled for 1/20/25.
Clinical Supervisor will utilize internal tracking system to monitor case consult due dates to ensure completion by established time frame. Implemented as of 1/15/25 and will continue to monitor on biweekly basis. |