INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13, 2009 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on December 10, 2009.
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Plan of Correction
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document that work done by the client at the project is an integral part of the treatment and rehabilitation plan in two of four client records.The findings include:Four client records were reviewed on November 13, 2009. Verification of work as an integral part of the treatment and rehabilitation plan was required in four client records. The facility did not document work as an integral part of the treatment and rehabilitation plan in client records # 3 and 4.Client Record # 3 - The client was admitted 7-22-09 and discharged 10-19-09. The treatment plan was completed on 7-23-09 with treatment plan updates completed on 8-24-09, 9-14-09 and 9-20-09. Verification of work as an integral part of the treatment and rehabilitation plan for work done by the client at the project was not documented on treatment plans or the treatment plan updates.Client record # 4 - The client was admitted 9-11-09 and discharged 9-28-09. The treatment plan was completed on 9-15-09. Verification of work as an integral part of the treatment and rehabilitation plan for work done by the client at the project was not documented on the treatment plan.
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Plan of Correction
Program director will conduct an in-service with all counselors regarding the inclusion of work as part of the treatment and rehabilitation plan. Program director will monitor adherence via monthly chart monitors. |