INITIAL COMMENTS
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| This report is a result of an on-site licensure renewal inspection conducted on November 22, 2010 through November 23, 2010 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 |
Plan of Correction
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705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to ensure all eating, drinking, and cooking utensils were stored in a clean enclosed area. The findings include:The facility's physical plant was inspected on November 22, 2010 at 11:45 am. During this inspection it was found that eating and cooking utensils were stored in a plastic basin on the second tier of an open shelf. Plates, bowls, and cups were stored uncovered on the first tier.
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Plan of Correction
Program Director has talked with Maintenance Supervisor regarding the area in which the eating and cooking utensils are currently stored. A maitenance project was approved in which closed shelving and drawers will be built for storage of these items. The full time maintenance person on site will follow through with this project. Program Director and Maintenance Supervisor will oversee the project to ensure its' completion by 1/7/2011. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.The findings include:A review of the fire drill logs was conducted on November 23, 2010. Documentation of a fire drill conducted during sleeping hours is required once every six months. The only fire drill conducted during sleeping hours in the past twelve months was conducted on June 30, 2010. Prior to that date, the only other sleeping drill was conducted on October 29, 2009.
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Plan of Correction
Program Director spoke to on site Maintenance staff who currently conducts all fire drills on 12/6/2010. He was informed and educated on the fact that one sleeping fire drill needs completed every 6 months. On site Maintenance staff will conduct a sleeping fire drill once every 6 months, with the first one being completed by 12/31/2010. The documentation of these drills will be inspected by Program Director and on site Risk Committee monthly to ensure compliance of all fire drills. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included the client's problems/needs that can or cannot be resolved in treatment, assets/strengths that can contribute to the resolution of client's problems, support systems, coping mechanisms, negative factors that might affect client's treatment, client's attitude toward treatment, and counselor's conclusion/impressions regarding client's attitude toward treatment in seven of ten client records reviewed.The findings include:Ten client records were reviewed on October 22, 2010 for psychosocial evaluations. Seven client records did not include a clinical assessment of the client; and only included client-reported historical information. Client # 1 was admitted on September 22, 2010. The psychosocial evaluation was completed on September 22, 2010 and did not include the client's assets/strengths and support systems, negative factors that may affect the client's treatment, and the client's attitude towards treatment. Client # 2 was admitted on October 1, 2010. The psychosocial evaluation was completed on October 1, 2010 and did not include the client ' s assets/strengths and counselors conclusions and impressions.Client # 4 was admitted on September 1, 2010. The psychosocial evaluation was completed on September 1, 2010 and did not include the client's problems/needs that can or cannot be resolved in treatment, assets and strengths, coping mechanisms, and negative factors that can affect treatment.Client # 5 was admitted on October 6, 2010. The psychosocial evaluation was completed on October 7, 2010 and did not include the client's problems/needs that can or cannot be resolved in treatment, and coping mechanisms.Client # 6 was admitted on July 27, 2010. The psychosocial evaluation was completed on July 28, 2010 and did not include a composite picture and the client's assets/strengths.Client # 7 was admitted on August 5, 2010. The psychosocial evaluation was completed on August 6, 2010 and did not include the client's problems/needs that can or cannot be resolved in treatment, assets and strengths, coping mechanisms, and negative factors that can affect treatment.
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Plan of Correction
Program Director will conduct an in-service with all counselors to instruct them on the details of a psychosocial evaluation. Included will be the inclusion of client's problems/needs, assets/strenghts, support systems, coping mechanisms, negative factors that might interfere with treatment, client's attitude toward treatment, and counselor's conclusion/impression. Examples of good, thorough psychosocial evaluations will be shared. The in-service will be conducted by 12/31/2010. Compliance will be ensured by Program Director via open and closed chart monitors monthly. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of services in the individual treatment and rehabilitation plan in seven of ten inpatient client records.The findings include:Ten outpatient client records were reviewed on November 22 through 23, 2010. The type and frequency of services were required in the individual treatment and rehabilitation plan in ten client records. The facility did not document the type and frequency of services in the individual treatment and rehabilitation plan in client records #8, 9, 10, 11, 12, 13, and 14.Client # 1 was admitted on September 22, 2010. The treatment plan was completed on September 22, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services. Client # 2 was admitted on October 1, 2010. The treatment plan was completed on October 1, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services. Client # 4 was admitted on September 1, 2010. The treatment plan was completed on September 1, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services. Client # 5 was admitted on October 6, 2010. The treatment plan was completed on October 7, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services. Client # 6 was admitted on July 27, 2010. The treatment plan was completed on July 28, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services. Client # 7 was admitted on August 5, 2010. The treatment plan was completed on August 6, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services. Client # 8 was admitted on August 12, 2010. The treatment plan was completed on August 13, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services. Client # 9 was admitted on August 27, 2010. The treatment plan was completed on August 27, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services. Client # 10 was admitted on July 21, 2010. The treatment plan was completed on July 21, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services.
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Plan of Correction
Program Director will hold in-service for all counselors to review the inclusion of type and frequency of treatment and rehabilitation services in the individual treatment plan. This in-service will be conducted by 12/31/2010. Compliance will be ensured by Program Director via open and closed chart monitors monthly. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on November 23, 2010 and an interview with the Facility Director , the facility failed to ensure that there was one Full Time Equivalent (FTE) Counselor for every eight clients.The findings include: On November 23, 2010 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed the facility director/clinical supervisor and three counselors as the clinical staff. The three counselors were documented as providing treatment for 25 clients. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.Based on the total number of hours per week that the facility reported the employees devoted to the clients (120), the total number of hours in the facility's standard work week, 40 , and the total number of clients on November 23, 2010 (25), the facility failed to ensure that there was one Full Time Equivalent (FTE) Counselor for every eight clients.Based on the number of hours the three counselors worked at this facility, and the number of clients on the counselors' caseload, one counselor exceeded the client to counselor ratio of 8:1. Employee hours (120/40 = 3 FTE)25 clients/3 FTE = 1 FTE per every 9 clients)This was confirmed with the Facility Director.
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Plan of Correction
Program Director will bring facility ratio into compliance of 8:1 by 1/3/2011 via program director carrying 1 client at all times. Program Director will monitor the number of clients of each caseload on a weekly basis via census to ensure the ratio remains 8:1. Program Director will also obtain board approval to request an exception be granted to the 8:1 ratio as the nature of halfway house treatment is less intense than that of a typical inpatient/residential facility. If this is not approved, the facility director will continue to monitor ratio numbers to ensure that it remains 8:1. |