INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 14, 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 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information prior to releasing information in one out of seven records reviewed.
Client #4 was admitted on January 27, 2023 and was still active at the time of the inspection. There was not an informed and voluntary consent from the client for the disclosure of information for the funding source documented in the client record, however; facility staff confirmed billing had occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On March 15th, all staff were re-trained on proper completion of releases of information including how to locate and confirm a client's funding source. All new hires will complete Confidentiality training which includes completion of consents in Relias. Routine monitoring will take place on a month basis by the Quality Specialist Team to review if releases of information completed based off applicable licensing and funder expectation. |
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 the review of client records, the facility failed to document case consultations within time frame identified in the facility's policy and procedures manual of every ninety days in one out of three applicable client records.
Client #7 was admitted on October 19, 2022 and discharged on February 22, 2023. There was no case consultation documented in the client record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/12/2023, case trackers will be reviewed and implemented with all staff to utilize for caseload management. Case trackers will monitor attendance, treatment plan due dates, case consult due dates and ASAM updates. The caseload tracker will be reviewed for each counselor at weekly staff meeting. If a client is in need of a case consult, the clinician will conduct review during staff meeting and complete the case consult in the client's electronic record. Routine monitoring will also be conducted on a monthly basis by the Quality Specialist Team to review if case consultations completed based off applicable licensing and funder expectations. |
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 a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of three discharged records reviewed.
Client #5 was admitted on August 30, 2022 and was discharged on November 3, 2022.
Client #6 was admitted on October 11, 2022 and was discharged on February 8, 2023.
Client #7 was admitted on October 19, 2022 and was discharged on February 22, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Pyramid Healthcare written policy for client discharge from the program is that all clients will be called within 7 days of the discharge date. To ensure proper completion of the 7-day follow-up calls, the director will print a discharge list for all clients discharged the week prior and present this list at weekly staff meeting. All staff will be provided with their list of clients to contact. Director will do an end-of-the-week audit on 50% of the discharge list and confirm the call logs are completed. Routine monitoring will also be conducted on a monthly basis to review whether re-engagement/follow up call is documented post-discharge. |