INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19-21, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc. - Transitions 2 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 January 31, 2008.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based upon review of personnel records reviewed on December 20, 2007, two of 12 staff members had not yet received the mandatory training for HIV/Aids and/or TB/STD. Staff members #4 & 10 had not yet received the HIV/AIDS training and staff member 10 had not yet received the TB/STD training.
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Plan of Correction
Staff Member #10 had HIV/AIDS training but it was omitted from the Grid. Staff member #4 was hired 5/31/07 and therefore was not yet required to have the training. The Program Director and Human Resources Coordinator will work in tandem to insure that all required trainings are completed in a timely fashion. This will be monitored for compliance by use of the Training Log completed by HR and sent to the the Program Director monthly beginning 3/1/08. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based upon review of the staffing records and census records for the detoxification unit on December 21, 2007, the facility failed to ensure that there was one FTE primary care staff person available for every seven clients during primary care hours. The facility only had one FTE primary care staff person available for the time frame of 11:00 PM until 7:00 AM for November 13 - 14, November 14 - 15, and November 15 -16.
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Plan of Correction
When detoxification census reaches 8 clients the 3-11 p.m. staff nurse or the 7-3 p.m. next day staff nurse will be added to cover the 11-7 a.m. overnight for a full compliment of nurses. The ADON will schedule for compliance beginning 3/1/08 or before. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based upon a review of client records on January 21, 2007, 3 of 4 client records reviewed failed to provide a complete medical history. Client records #1, 3 & 7 lacked family medical history and failed to address client symptoms.
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Plan of Correction
Program Director will initiate a plan for current staff to insure facility policy compliance on the completion of client family medical history as well as client symptoms. The plan will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors beginning 3/1/08. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon a review of client records on January 21, 2007, 3 of 4 client records reviewed failed to provide a complete personal history prior to the completion of the psychosocial evaluation. Client records #3 & 7 contained personal histories that were completed after the psychosocial evaluation and client record #5 lacked a date and signature to verify if the history had been reviewed by the clinician.
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Plan of Correction
Program Director will initiate a training plan for current staff to address facility policy compliance on completion of personal histories before the completion of the psychosocial evaluation and verification of clinical review via clinician signature and date of review. The plan will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Direction during regular monthly chart monitors beginning 3/1/08. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of client records on January 21, 2007, 3 of 4 client records reviewed showed that the psychosocial evaluations had been completed prior to the completion of the client's personal history. Client records #3, 5 & 7 contained psychosocial evaluations that had been completed prior to the completion of the client's personal histories.
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Plan of Correction
Program Director will initiate a training plan for current staff to address facility policy compliance on the completion of personal histories by the third session of treatment prior to the completion of the psychosocial evaluation by the fifth session of treatment. The plan will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors beginning 3/1/08. |
709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based upon a review of client records on January 21, 2007, 1 of 3 client records reviewed, client record #1, contained a preliminary treatment plan that had not been signed by the client and there was no other documentation to demonstrate that the plan had been developed with the client.
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Plan of Correction
Program Director will initiate a training plan for current staff to address facility policy compliance on the correct completion of the client preliminary treatment plan that demonstrates client participation in the development of the preliminary treatment plan and verifies this via client signature and date. The plan will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors beginning 3/1/08. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based upon a review of client records on January 21, 2007, the facility failed to complete the comprehensive individualized treatment plan as per facility time frames in 1 of 3 client records reviewed. The comprehensive treatment plan had not been signed by the client by the fifth session as required by facility procedure.
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Plan of Correction
Program Director will initiate a training plan for current staff to address policy compliance on facility policy time frames for comprehensive treatment plans that includes the client signature by the fifth session of treatment. The plan will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors beginning 3/1/08. |
709.83(a)(5) LICENSURE Client records
709.83. 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:
(5) Medication records.
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Observations
Based upon a review of client records on January 21, 2007, the facility failed to properly document client medications in 2 of 3 client records reviewed. Client records #1 & 3 lacked information regarding how frequently the medications were to be taken. Client record #3 contained a listing for one medication where the dosage was not legible due to being written over and it was not possible to determine if the amount was to be 15 or 25 mg.
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Plan of Correction
Program Director will initiate a training plan for current staff to address policy compliance on completion of client medication records that includes documentation on how frequently medications are to be taken and includes legible documentation on medication dosage. The plan will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors beginning 3/1/08. |
709.83(a)(6) LICENSURE Client records
709.83. 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 upon a review of client records on January 21, 2007, 1 of 1 client records reviewed, specifically client record #1, failed to provide time frames for the completion of goals in the aftercare plan.
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Plan of Correction
Program Director will initiate a training plan for current staff to address policy compliance on the completion of the aftercare plan that clearly documents time frames for the completion of goals.
The plan will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors beginning 3/1/08.
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709.83(a)(8) LICENSURE Client records
709.83. 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) Record of services provided.
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Observations
Based upon a review of client records on January 21, 2007, the facility failed to provide a complete record of services provided in 2 of 3 records reviewed. Client record #1 lacked a complete record of service for group sessions provided and client record #3 lacked a complete record of services for both group and individual sessions.
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Plan of Correction
Program Director will initiate a training plan for current staff to address policy compliance on the completion of the record of service that provides a complete record of service, including documentation for group and individual services. The plan will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors beginning 3/1/08. |
709.83(a)(10) LICENSURE Client records
709.83. 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 upon a review of client records on January 21, 2007, the facility failed to provide a discharge summary in 1 of 2 records reviewed where discharge summaries were due. Client record #3 lacked a discharge summary.
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Plan of Correction
Program Director will initiate a training plan for current staff to address policy compliance on the timely completion of the client discharge summary for each and every discharged client. The plan will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors beginning 3/1/08. |
709.83(a)(11) LICENSURE Client records
709.83. 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 upon a review of client records on January 21, 2007, the facility failed to complete a follow up in 1 of 2 records reviewed where follow up contacts were due. Client record #1 lacked documentation to show that a follow up had been done.
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Plan of Correction
Program Director will initiate a training plan for current staff to address policy compliance on documentation of timely follow up information to demonstrate that a follow up has been done. The plan will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors beginning 3/1/08. |
709.28(c)(2) 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. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based upon a review of client records on January 21, 2007, 6 of 8 client records reviewed failed to identify the specific information to be disclosed. Client records #1, 2, 3, 5, 6 & 8 contained consent to release information forms to family members, medical doctors and/or the bureau of drug and alcohol services which did not specify what was being released.
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Plan of Correction
Program Director or Clinical Director will initiate training for current staff to address policy compliance on completion of the client consent to release information that clearly specifies what client information is to be released. The training will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director, Clinical Director and ADON during regular monthly chart monitors beginning 3/1/08. |
709.28(c)(3) 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. The consent shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based upon a review of client records on January 21, 2007, 4 of 8 client records reviewed failed to identify the purpose for the disclosure of information. Client records #1, 3, 5, & 6 contained consent to release information forms to family members and/or the bureau of drug and alcohol services which did not specify the purpose for releasing the information.
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Plan of Correction
Program Director or Clinical Director will initiate training for current staff to address policy compliance on completion of the client consent to release information that clearly specifies for what purpose the client's information is to be released. The training will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director, Clinical Director and ADON during regular monthly chart monitors beginning 3/1/08. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Based upon a review of client records on January 21, 2007, the facility failed to document all areas of the physical examinations in 3 of 4 records reviewed. Client records #2, 4 & 6 failed to provide the physician's impressions. Client record #4 lacked a complete review of organ systems.
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Plan of Correction
A memorandum will go out to all physicians requiring completeness of the History & Physical (H&P), including physician impressions. The ADON and Medical Administrative Assistant will monitor charts after the H&P is completed for compliance beginning 3/1/08. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon a review of client records on January 21, 2007, 4 of 4 client records reviewed failed to provide a complete personal history. Client records #2, 4, 6 & 8 contained personal histories that contained incomplete information in the areas of family history, employment/vocational history, recreational history and sexual history. Client records #2, 6 & 8 failed to address legal history.
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Plan of Correction
All clinical staff will have a day-long training to examine how, when and for what purpose all clinical documentation is completed including, but not limited to, psychosocial histories, evaluations, treatment plans, treatment plan reviews, group and individual notes and discharge summaries. This will aid in a more full understanding of the system as outlined by both licensure and Pyramid Healthcare. Charts will be monitored for compliance by the Clinical Supervisor by use of the monthly chart monitor beginning 3/1/08. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based upon a review of client records on January 21, 2007, the facility failed to document all areas of the physical examinations in 3 of 4 client records reviewed. Client records #2, 4 & 6 failed to provide the physician's impressions. Client record #4 lacked a complete review of organ systems.
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Plan of Correction
A memorandum will go out to all physicians requiring completeness of the History & Physical (H&P), including physician impressions. The ADON and Medical Administrative Assistant will monitor charts after the H&P is completed for compliance beginning 3/1/08. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based upon a review of client records on January 21, 2007, the facility failed to provide an individualized treatment plan developed with the client within facility time frames and as per policy and procedures in 2 of 2 client records reviewed. Client record #2 contained a treatment plan that had not been signed by the client and there was no other documentation to demonstrate that the plan had been developed with the client. Client record #8 contained a treatment plan that was developed prior to the completion of the psychosocial evaluation.
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Plan of Correction
All clinical staff will have a day-long training to examine how, when and for what purpose all clinical documentation is completed including, but not limited to, psychosocial histories, evaluations, treatment plans, treatment plan reviews, group and individual notes and discharge summaries. This will aid in a more full understanding of the system as outlined by both licensure and Pyramid Healthcare. Charts will be monitored for compliance by the Clinical Supervisor by use of the monthly chart monitor beginning 3/1/08. |
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 upon a review of client records on January 21, 2007, the facility failed to provide a treatment plan update that addressed the issues identified on the the prior treatment plan and provided a report on progress in 1 of 1 client records reviewed, specifically client record #8.
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Plan of Correction
All clinical staff will have a day-long training to examine how, when and for what purpose all clinical documentation is completed including, but not limited to, psychosocial histories, evaluations, treatment plans, treatment plan reviews, group and individual notes and discharge summaries. This will aid in a more full understanding of the system as outlined by both licensure and Pyramid Healthcare. Charts will be monitored for compliance by the Clinical Supervisor by use of the monthly chart monitor beginning 3/1/08. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based upon a review of client records on January 21, 2007, the facility failed to document the data and/or provide a clinical assessment in the progress notes in 2 of 4 client records reviewed. Client record #2 contained group notes that lacked data and failed to provide an assessment of the group and client. Client record #8 contained group notes on the following dates which lacked any topic and failed to provide group dynamics: 7/23/07, 7/24/07,7/25/07,7/26/07, 7/31/07, 8/1/07, 8/2/07 & 8/3/07.
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Plan of Correction
All clinical staff will have a day-long training to examine how, when and for what purpose all clinical documentation is completed including, but not limited to, psychosocial histories, evaluations, treatment plans, treatment plan reviews, group and individual notes and discharge summaries. This will aid in a more full understanding of the system as outlined by both licensure and Pyramid Healthcare. Charts will be monitored for compliance by the Clinical Supervisor by use of the monthly chart monitor beginning 3/1/08. |
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 upon a review of client records on January 21, 2007, the facility failed to document the reason for treatment in the discharge summaries for 3 of 3 records reviewed, #2, 6 & 8.
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Plan of Correction
All clinical staff will have a day-long training to examine how, when and for what purpose all clinical documentation is completed including, but not limited to, psychosocial histories, evaluations, treatment plans, treatment plan reviews, group and individual notes and discharge summaries. This will aid in a more full understanding of the system as outlined by both licensure and Pyramid Healthcare. Charts will be monitored for compliance by the Clinical Supervisor by use of the monthly chart monitor beginning 3/1/08. |
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 upon a review of client records on January 21, 2007, the facility failed to complete a follow up in 3 of 3 records reviewed
The findings were: Client records #2, 6 & 8 lacked documentation to show that a follow up had been done.
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Plan of Correction
Follow-up calls will be completed by the receptionist and/or Administrative Assistant in a timely fashion, documented and sent to the Medical Records Coordinator who will monitor for compliance beginning 3/1/08. |