INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19, 2021 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of nine personnel records, it was discovered that employee #6, who was hired as a counselor on June 28, 2021, did not meet the experience requirements to be a counselor. At the time of the hire, the employee only had seven months of clinical experience. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Prior to hiring any potential employees for the position of counselor the Clinical Director and Executive Director will review the candidate's qualifications with the regional quality management team to ensure they all applicants meet the minimum qualifications for the position as set forth in DDAP regulations to years of clinical experience in a health or human service agency to equal at minimum one year of experience and to ensure that the applicant's degree type is identified as an acceptable degree by DDAP regulations. The HR recruiter, Clinical Supervisor and Executive Director will ensure that the months/years of experience is documented on the employment application as well as on the resume and meets the necessary one year of clinical experience standard prior to employee starting in counseling position. The Clinical Supervisor and Executive Director will ensure that the degree meets the DDAP standards for an acceptable field for the counseling position and is documented on the employment application as well as on the resume. Employee #6 will be reclassified as a counselor assistant and will receive all necessary supervision as such until she meets the requirements of counselor in November 2021. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection, the facility failed to maintain furnishings in a state of good repair as the men ' s lounge had a couch that the right side was broken resulting in the wooden frame being visible from the cushion.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Maintenance supervisor will complete visual inspection of the building on a weekly basis and will inspect furniture in all lounges and common areas as well a client rooms and will document this inspection on a spreadsheet with a check off of each room inspected and will be given to the executive director. Any furniture that is in disrepair will be removed from the area and replaced. Staff will fill out a maintenance request for any items they see as being broken so it can be removed from the area. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure that counseling cannot be seen or heard outside the counseling room as the detox room 148 and the men ' s lounge which are both used for groups and windows that were not covered. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Maintenance supervisor will complete visual inspection of the building on a weekly basis and will inspect rooms that are designated as counseling spaces to ensure that window coverings are present and will log building inspections and results on a spreadsheet to be shared with Executive Director. During inspection these rooms were rectified and window coverings were placed on windows. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drills from October 2020 thru July 2021, the facility failed to conduct unannounced fire drills at least once a month as the facility failed to provide documentation for fire drills conducted in December 2020 and June 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Maintenance Supervisor will ensure that fire drills are being completed on a monthly basis with adherence to DDAP standards. All fire drills will be documented and uploaded to the tracking Smartsheet within 24 hours of the drill being completed. In the event that the maintenance supervisor is unable to complete a drill the supervisor will notify the Executive Director and the ED or designee will complete the drill as required and document the outcome of the drill. The Smartsheet for the drill will be reviewed on a bi-weekly basis by the supervisor and ED to ensure that all drills are completed and documented in a timely manner. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drills from October 2020 thru July 2021 the facility failed to ensure that written fire drills included the exit route used on fire drills conducted on October 31, 2020 and November 30, 2020.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Executive Director has met with the maintenance supervisor on 8/19/2021 and reviewed the requirement of exit routes being clearly marked on the fire drill log. The Smartsheet used to track this is a required field so that this information must be included in the fire drill results/outcome. Executive Director will review on a monthly basis to ensure that this information is being captured on the fire drill log. |
709.62(c)(3)(i) LICENSURE Medical history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of seven client record the facility failed to complete and document medical history in three applicable records. Client record #5 was admitted on June 1, 2021 and discharged on June 8th, 2021. Client record #6 was admitted on May 12, 2021 and discharged on May 17, 2021. Client record #7 was admitted on February 19, 2021 and discharged on February 23, 2021. These findings were discussed with facility staff during in the inspection process.
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Plan of Correction
Office Manager, Nursing Manager and Executive Director will review charts for completion health and physical's to include medical history. The health and physical will be tracked on a Smartsheet to ensure completion in adherence to DDAP regulations. Medical providers will be re-educated the week of October 4, 2021 and will be documented in a sign off that re-training was received. Medical history will also be documented in the LOCA completed by the clinicians during that process. Clinicians were re-educated on LOCA completion during group supervision with week of September 13, 2021. This will be part of chart monitoring each month to ensure adherence to regulation. |
709.62(c)(3)(ii) LICENSURE D & A History
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of seven client record the facility failed to complete and document drug or alcohol history, or both in three applicable records. Client record #5 was admitted on June 1, 2021 and discharged on June 8th, 2021. Client record #6 was admitted on May 12, 2021 and discharged on May 17, 2021. Client record #7 was admitted on February 19, 2021 and discharged on February 23, 2021. These findings were discussed with facility staff during in the inspection process.
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Plan of Correction
Office Manager, Nursing Manager and Executive Director will review charts for completion of face to face determination of SA history each month to ensure that the documents are clearly completed as a part of the health and physical and viewable within the chart to ensure that regulations for DDAP are being met. 25% of total population will be reviewed each month beginning October 1, 2021 and providers will be re-educated the week of October 4, 2021 on the information necessary to be included in the drug and alcohol history. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of seven client record the facility failed to complete and document personal history in three applicable records. Client record #5 was admitted on June 1, 2021 and discharged on June 8th, 2021. Client record #6 was admitted on May 12, 2021 and discharged on May 17, 2021. Client record #7 was admitted on February 19, 2021 and discharged on February 23, 2021. These findings were discussed with facility staff during in the inspection process.
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Plan of Correction
The Clinical Director and Intake/Case Coordination Supervisor will schedule LOCA's to be completed in the Assessment Counselors or Counselor's schedules if the LOCA has not been completed within 48 hours of arrival at the facility. To ensure that LOCA's that includes personal history are being completed as required the Clinical Director (for residential) and the Intake Supervisor (for detox) will complete 100% review of cases for the months of September and October in order to track the completion of LOCA's in adherence with the regulations. Clinical Director and Intake Supervisor will review these standards and what is required to be documented- this has been reviewed during group supervision the week of September 13, 2021 Ongoing supervision will be provided to all clinicians and Assessment Counselors regarding the DDAP regulations as it related to LOCA completion and what is required to be included with regards to personal history. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven client records the facility failed to complete and document psychosocial evaluations in three applicable records. Client record #5 was admitted on June 1, 2021 and discharged on June 8th, 2021. Client record #6 was admitted on May 12, 2021 and discharged on May 17, 2021. Client record #7 was admitted on February 19, 2021 and discharged on February 23, 2021. These findings were discussed with facility staff during in the inspection process.
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Plan of Correction
The ED, Clinical Director and Intake/Case Coordination Supervisor will schedule LOCA's and psychosocial to be completed in the Assessment Counselors or Counselor's schedules if the LOCA has not been completed within 48 hours of arrival at the facility. To ensure that LOCA's and psychosocials are being completed as required the Clinical Director (for residential) and the Intake Supervisor (for detox) will complete 100% review of cases for the months of September and October in order to track the completion of LOCA's in adherence with the regulations. Clinical Director and Intake Supervisor will review these standards in upcoming supervisions scheduled during September. A LOCA tracking smart sheet will be used on a daily basis beginning the week of September 13, 2021 to identify individuals that have come into treatment, the date they arrived, due date of the LOCA, if the LOCA was completed and by whom. This will be updated daily by the Clinical Director, Intake Supervisor and Executive Director or designee to provide real time data of the completion rate of LOCA's. Ongoing supervision will be provided to all clinicians and Assessment Counselors regarding the DDAP regulations as it related to LOCA completion. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of seven client records the facility failed to ensure that one of the three applicable discharge clients received an aftercare plan. Client record #7 was admitted on February 19, 2021 and discharged on February 23, 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical Director and Intake/Case Coordinator will re-train all clinical staff and case coordinator staff regarding the standards as it relates to aftercare planning, discharge planning and completion of discharge summaries the week of October 4, 2021. Aftercare plans will be completed 24 hours prior to the individual leaving treatment for planned discharges and a copy of the plan will be given to the client. For non scheduled discharges aftercare will be offered and encouraged as part of discharge and client refusal will be documented. 25% of patient population discharge chart will be reviewed each month for completion. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of seven client records the facility failed to ensure that one of the three applicable discharge clients received a discharge summary. Client record #7 was admitted on February 19, 2021 and discharged on February 23, 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical Director and Intake/Case Coordinator will re-train all clinical staff and case coordinator staff regarding the standards of completion of discharge summaries the week of October 4, 2021. Discharge summaries will be completed within 7 days of an individual leaving treatment. 25% of patient population discharge chart will be reviewed each month for completion by the clinical director or designee. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of seven client records the facility failed to ensure that two of the three applicable discharge client ' s record documented follow up information. Client record #6 was admitted on May 12, 2021 and discharged on May 17, 2021. Client record #7 was admitted on February 19, 2021 and discharged on February 23, 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Case Coordinators are required to contact each individual who has been discharged within 7 days of discharge. Case coordinators are required to document the follow up phone call in a Memo to chart with the content of the phone call. Random Chart audits are conducted on a monthly basis by the Intake/Case Coordinator Supervisor to ensure compliance to the regulations and will be documented and shared with Executive Director for tracking purposes. All case coordinators will be re-trained in these standards as part of group supervision the week of October 4, 2021 and this will be reviewed during subsequent supervisions to ensure adherence to standards. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three client records reviewed.Client #10 was admitted on May 28, 2021 and was still active at the time of the inspection. A treatment plan update was completed on June 22, 2021 and the next update was due no later than July 22, 2021; however, there was no update documented in the record until August 10, 2021. Client #13 was admitted on May 24, 2021 and was discharged on August 2, 2021. A treatment plan update was completed on May 26, 2021 and the next update was due no later than June 26, 2021; however, there was no update documented in the record until August 2, 2021. Client #14 was admitted February 10, 2021 and was discharged on June 10, 2021. A treatment plan update was completed on April 1, 2021 the next update was due no later than May 1, 2021; however, there was no update documented in the record until May 13, 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
a. Treatment plan updates will occur according to regulatory standards. The Clinical Director and Lead Counselor will develop a smartsheet with due dates for each clinician in order to track due dates for treatment plans. Clinicians will be expected to have treatment plans completed as per the regulations (14 or 30 days depending upon the level of care of the PIR)
b. Clinical Director will complete 100% review of all treatment plans to ensure all treatment plans are completed with the PIR and documented in the chart with the PIR's signature that signifies they are in agreement with the plan and have been involved in the creating of the plan. The clinical director will not sign the plan if the PIR's signature is not present.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 client records, the facility failed to ensure that all client received counseling services according to the individual treatment plan in all seven inpatient client records reviewed. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
All clients are offered group counseling 5 days per week and this is documented in group notes. Clinical Director will re-train clinical team on documentation standards and best practices for progress note writing to include strengths based language, incorporating treatment plan goals and specific interventions used during session. If a session does not follow the treatment plan the clinician will specify the reason for the deviation and if this is a new identified area of concern or something that is expected to carry over into other sessions a treatment plan update will be completed to add a new goal and objectives to address the area of concern.
b. Clinical Director will audit 50% of all progress notes on a weekly basis for the months of September and October to ensure that notes are reflective of the treatment plan and will provide feedback to clinicians as part of supervisor. If improvements are noted then CD will complete 100% audit of 2 charts per clinician each month (25% of residential population) at random each month moving forward. On-going supervision and training will be provided each month to support clinicians and re-enforce appropriate documentation.
If client refuses to attend groups or individual sessions or misses a session due to illness or another appointment this will be documented in a memo to chart.
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709.53(a)(9) LICENSURE Aftercare plans
709.53. 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 seven client records the facility failed to ensure that one of two applicable discharge clients received an aftercare plan. Client record #13 was admitted on May 24, 2021 and discharged on August 2, 2021.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical Director and Intake/Case Coordinator will re-train all clinical staff and case coordinator staff regarding the standards as it relates to aftercare planning, discharge planning and completion of discharge summaries the week of October 4, 2021. Aftercare plans will be completed 24 hours prior to the individual leaving treatment for planned discharges and a copy of the plan will be given to the client. For non scheduled discharges aftercare will be offered and encouraged as part of discharge and client refusal will be documented. 25% of patient population discharge chart will be reviewed each month for completion. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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 review of seven client records the facility failed to ensure that two of the three applicable discharge clients received a discharged summary. Client record #12 was admitted on January 28th, 2021 and discharged on March 3, 2021.Client record #13 was admitted on May 24, 2021 and discharged on August 2, 2021.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical Director and Intake/Case Coordinator will re-train all clinical staff and case coordinator staff regarding the standards of completion of discharge summaries the week of October 4, 2021. Discharge summaries will be completed within 7 days of an individual leaving treatment. 25% of patient population discharge chart will be reviewed each month for completion by the clinical director or designee. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 seven client records the facility failed to ensure that two of the three applicable discharge clients documented follow up information. Client record #13 was admitted on May 24, 2021 and discharged on August 2, 2021.Client record #14 was admitted on February 10, 2021 and discharged on June 10, 2021.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Case Coordinators are required to contact each individual who has been discharged within 7 days of discharge. Case coordinators are required to document the follow up phone call in a Memo to chart with the content of the phone call. Random Chart audits are conducted on a monthly basis by the Intake/Case Coordinator Supervisor to ensure compliance to the regulations and will be documented and shared with Executive Director for tracking purposes. All case coordinators will be re-trained in these standards as part of group supervision the week of October 4, 2021 and this will be reviewed during subsequent supervisions to ensure adherence to standards.
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