INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 4-5, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Pyramid Healthcare Inc Allentown 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
During a licensing inspection conducted on September 4-5, 2019, the facility failed to provide documentation of one year of clinical experience for employee # 13.
Employee # 13 was hired as a counselor on August 12, 2019 and was still in this position at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This clinician has since been demoted via HR to a Counselor Assistant. She has been informed that her time at Valley Youth House does not count towards her required D and A time. She will be under going 3 months of supervision, weekly.
Moving forward HR will continue to review resumes for qualifying degrees and years of experience. Questions and uncertainty will be reviewed with internal compliance and regional clinical for consultation.
Likewise ED will reach out to DDAP with questions and clarity if unsure.
Counselor Assistants per pa licensing code with undergo weekly supervision. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
During a licensing inspection conducted on September 4-5, 2019, the facility failed to provide documentation of close supervision to include direct observation for at least the first six months of employment for employee # 12.
Employee # 12 was hired as a counselor assistant on July 29, 2019 and was still in this position at the time of the inspection. The Employee ' s personal record only documented supervision on August 21 and 28.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed with Clinical Director and Lead Counselor the supervision requirements. This counselor assistant will be met with weekly for the next six months. Clinical Director will complete chart audit of supervision binder monthly to ensure supervision is being conducted as expected. Clinical Director will ensure all staff are supervised and met with based on DDAP expectation according to their qualifications. |
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
During a licensing inspection conducted on September 4-5, 2019, the facility failed to ensure that employee # 14 received the minimum of 6 hours of HIV/AIDS training and other health related topics within the regulatory timeframe.
Employee # 14 was hired as a Certified Recovery Specialist on March 11, 2017 and was due to have the communicable disease trainings no later than March 11, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff member was informed of her need to complete the required training immediately. This staff will be attending assigned additional training in the near future.
ED will be reviewing staff training requirements with HR monthly and developing tracking tools and checklist.
Staff will be provided a checklist of trainings required with in their first year and follow their annual training plans.
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709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
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Observations
During a Project Wide review of Policy and Procedures, the facilities Client Rights policy was missing - sex and marital status in 709.30 (2), and Reasons for removing sections shall be documented in the record in 709.30 (3).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The new form to be added to Carelogic for all programs by September 1, 2019. Program Director will ensure all staff are educated on the new form by September 15, 2019. |
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
During a licensing inspection conducted on September 4-5, 2019, the project failed to provide documentation of an informed and voluntary consent to disclose information form prior to disclosing information in 2 of 14 records reviewed.
Client # 1 was admitted on August 1, 2019 and was still active at the time of the inspection. A letter addressed to "whom it may concern" was sent on August 16, 2019.
Client # 7 was admitted on July 25, 2018 and discharged on August 14, 2018. An email stating that discharge paperwork was sent to a SCA on August 20, 2018 did not provide the information sent.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff meeting conducted on 9/24/19 reviewed and trained on releases and consents of information. Clinical Director and Executive Director reviewed the extent of information allowed to be release, how to correctly fill out releases. Likewise ensuring specific parties are named, addresses and specific phone numbers are identified, and timelines are kept.
Monthly chart audits will continue to ensure compliance and confidentiality.CD will review chart concerns and corrections with in clinical supervision.
Staff will be provided examples on correct releases and examples how to complete correctly.
Memos to chart will be notated in the client recorded out lining the concerns and need for specific releases will be attached should the client be returned.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
During a licensing inspection conducted on September 4-5, 2019, the project failed to provide documentation of written acknowledgment by the client that the client had been made aware of their rights in client record # ' s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14. Acknowledgment of client rights did not include "sex" on discrimination in the provision of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The new form to be added to Carelogic for all programs by September 1, 2019. Program Director will ensure all staff are educated on the new form by September 15, 2019.
Clients who are active will be provided the update client rights agreement and this will be reviewed.
Those who are no longer active; a memo to chart and note on the message board will notate a need for an update and if when they should return to treatment. |
709.81(b)(4) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
During a licensing inspection conducted on September 4-5, 2019, the facility failed to provide documentation of a complete orientation to include psychosocial evaluations and preliminary treatment plans in five of seven records reviewed.
Client # 3 was admitted on August 23, 2019 and was still active at the time of the inspection. The client record did not contain documentation of a psychosocial evaluation
Client # 4 was admitted on August 19, 2019 and was still active at the time of the inspection. The client record did not contain documentation of a psychosocial evaluation or preliminary treatment plan.
Client # 5 was admitted on October 18, 2018 and was discharged on February 18, 2019. The client record did not contain documentation of a preliminary treatment plan.
Client # 7 was admitted on July 25, 2018 and was discharged on August 14, 2018. The client record did not contain documentation of a preliminary treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Director will hold a training with in October on regulations concerning charting. Staff will be reminded about psycho socials needing to be completed at time of assessment. The preliminary treatment plan tool in Carelogic will be reviewed with staff and made mandatory at time of assessment. Staff will be provided a charting outline and audit conducting form of documentation expectations. |
709.82(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
During a licensing inspection conducted on September 4-5, 2019, the facility failed to provide documentation of the comprehensive treatment and rehabilitation plan to include individual therapy sessions twice weekly for Partial Hospitalization requirements.
Client # 5 was admitted on October 18, 2018 and discharged on February 18, 2019. The comprehensive treatment and rehabilitation plan developed on October 22, 2018 and last updated on January 7, 2019 indicated individual session weekly and did not specify 2 times weekly.
Client # 6 was admitted on June 24, 2019 and discharged on July 31, 2019. The comprehensive treatment and rehabilitation plan developed on June 24, 2019 indicated individual session bi-weekly and did not specify 2 times weekly.
Client # 7 was admitted on July 25, 2018 and discharged on August 24, 2018. The comprehensive treatment and rehabilitation plan developed on July 25, 2018 indicated individual session bi-weekly and did not specify 2 times weekly.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Director has since established weekly tracking and reporting system to PHP individual sessions are conducted. Staff will be held accountable.
Staff will review and complete training to ensure that recommendations made are held. Clients will undergo and be expected at the number of sessions specified.
Memos to chart and general document will notate if sessions are missed and or other reasoning's clients can not attend as required. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
During a licensing inspection conducted on September 4-5, 2019, the facility failed to provide documentation of Individual counseling sessions being conducted at least twice weekly for Partial hospitalization services in 6 of 7 records reviewed.
Client # 1 was admitted on August 1, 2019 and was still an active client at the time of the inspection. The chart's record of service and progress notes indicated that the client had not received two individual sessions the weeks of August 4-10, 11-17, and 25-31.
Client # 2 was admitted on August 22, 2019 and was still an active client at the time of the inspection. The chart's record of service and progress notes indicated that the client had not received two individual sessions the week of August 25-31.
Client # 4 was admitted on August 19, 2019 and was still an active client at the time of the inspection. The chart's record of service and progress notes indicated that the client had not received two individual sessions the week of August 25-31.
Client # 5 was admitted on October 18, 2018 and was discharged on February 8, 2019. The chart's record of service and progress notes indicated that the client had not received two individual sessions the weeks of October 21-27, 28- November 3, November 4-10, 11-17, 18-24, 25-December 1, 2-8, 9-15, 16-22, and 23-29. The last session documented was on January 3, 2019.
Client # 6 was admitted on June 24, 2019 and was discharged on July 31, 2019. The chart's record of service and progress notes indicated that the client had only received one individual session on June 24, 2019.
Client # 7 was admitted on July 25, 2018 and was discharged on August 14, 2018. The chart's record of service and progress notes indicated that the client had only received one individual session on August 10, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Director has since implemented weekly tracking and processes. Staff are assigned to a PHP client and appointments are blocked with in the schedules via admin assistant to ensure clients are met with. staff members not conducting this will be held accountable per ED and potential disciplinary action. |
709.83(a) 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:
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Observations
During a licensing inspection conducted on September 4-5, 2019, the facility failed to provide documentation of a complete client record to include referral contacts, discharge summaries, and follow-up information in four of seven records reviewed.
Client # 1 was admitted on August 1, 2019 and was still an active client at the time of the inspection. The client record did not contain documentation of a referral contact.
Client # 5 was admitted on October 18, 2018 and discharged on February 18, 2019. The client record did not contain documentation of a discharge summary or follow-up information.
Client # 6 was admitted on June 24, 2019 and discharged on July 31, 2019. The client record did not contain documentation of a discharge summary or follow-up information.
Client # 7 was admitted on July 25, 2018 and discharged on August 14, 2018. The client record did not contain documentation of a discharge summary or follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be help and will review discharge process. Clinicians will review with Executive Director successful and unsuccessful discharge expectations. Staff will be provide chart auditing, and monitoring too for self review.
Clinical Director and Regional team will conduct monthly chart auditing.
Deficiencies with in the chart audit will be reviewed with the staff member in supervision.
Staff members will be provided a copy of the chart audit tool for self auditing purposes.
Discharge Summaries and aftercare plans are to be sent to the Clinical Director for review. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
During a licensing inspection conducted on September 4-5, 2019, the narcotic treatment program failed to provide documentation of an emergency contact in Patient # 8's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained and reminded at weekly staff meeting about needing to obtain emergency consents. Should the staff member not be able to and or one is not identified this will be documented in the client record.
ED will provide training on appropriate consent drafting. CD and Regional Clinical team will conduct monthly chart audits to catch such issues in the future. Primary clinicians will be responsible for reviewing consents after level of care assessment. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
During a licensing inspection conducted on September 4-5, 2019, the facility failed to provide documentation of a complete intake and admission to include psychosocial evaluations and preliminary treatment plans in four of seven client records reviewed.
Client # 8 was admitted on April 29, 2019 and was still an active client at the time of the inspection. The client record did not contain documentation of a preliminary treatment plan.
Client # 10 was on August 13, 2019 and was still an active client at the time of the inspection. The client record did not contain documentation of a psychosocial evaluation.
Client # 12 was on February 8, 2019 and was discharged on May 14, 2019. The client record did not contain documentation of a psychosocial evaluation or a preliminary treatment plan.
Client # 13 was on December 26, 2018 and was discharged on February 25, 2019. The client record did not contain documentation of a preliminary treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Director will hold a training with in October on regulations concerning charting. Staff will be reminded about psycho socials needing to be completed at time of assessment. The preliminary treatment plan tool in Carelogic will be reviewed with staff and made mandatory at time of assessment. Staff will be provided a charting outline and audit conducting form of documentation expectations
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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
During a licensing inspection conducted on September 4-5, 2019, the project failed to provide documentation that the clients received counseling services according to their individual comprehensive treatment and rehabilitation plan in three of seven charts reviewed.
Client # 8 was admitted on April 29, 2019 and was still an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan dated April 30, 2019 and last updated August 29, 2019 indicated Individual sessions to occur bi-weekly. The chart's record of service and progress notes indicated that the client had not received individual sessions between June 19 and July 15 and July 15 through August 29.
Client # 11 was admitted on June 7, 2019 and was still an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan dated June 11, 2019 and last updated July 11, 2019 indicated Individual sessions to occur bi-weekly. The only documentation of an individual session in the client record occurred on June 11, 2019.
Client # 13 was admitted on December 26, 2018 and was discharged on February 25, 2019. The comprehensive treatment and rehabilitation plan dated January 25, 2019 indicated Individual sessions to occur bi-weekly. The only documentation of an individual session in the client record occurred on February 13, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director and Executive Director will review expectations and standards with staff in regards to reviewing the assessment tool and complying with the recommendation. Primary clinicians will adhere to clinical recommendation and aid client in attendance of these sessions. Should the client be unable to meet as expected this will be documentation. Calls logs and memos to chart will notate attendance concerns.
Clinical Director and Executive Director will be developing processes and tracking to ensure individual session are completed and clients are being held to their attendance.
Clinical Director will review attendance and ensure individual sessions are occurring as expected and outlined.
All clients will be met with weekly for individuals from the beginning until the clinician deems it appropriate to titrate and step-down or decrease sessions. |