INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 6-7, 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 November 4, 2009.
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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 on a review of six personnel and training records on October 5, 2009, a review of the information contained on the facility summary report on October 7, 2009, and a conversation with the human resource staff member on October 7, 2009, the facility failed to ensure that all applicable staff members received the required mandatory communicable disease training within two years of the hire date for support staff. Of the sixty eight support staff who are required for the training, sixteen do not have the training documented.
The findings include:
The staffing requirements facility summary report was reviewed on October 7, 2009. Twelve support staff members (# 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19) did not have the required STD/TB training, and four support staff members (13, 16, 18, 19) did not have the required HIV/AIDS training.
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Plan of Correction
On an ongoing basis the Program Director will ensure compliance with regard to meeting staff training requirements through quarterly reviews of training records with Human Resources staff. An appointed and qualified nursing staff member will provide training in the areas of both STD/TB and HIV/AIDS on a regular basis. |
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
Based on a review of client records, the facility failed to provide the frequency for individual sessions on the treatment plans in two of the two required records.
The findings include:
Sixteen client records were reviewed on October 6-7, 2009. Four of these sixteen records were from the partial hospitalization activity. Two of those four records were required to document treatment plans which included the type and frequency of treatment. The frequency of the treatment of the individual sessions is not addressed on the treatment plans in client records # 11 and 12.
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Plan of Correction
The Program Director will meet with the counselor who was the counselor for clients #11 and #12 regarding treatment planning. Discussions/training will specifically focus on the importance of (1)individualization of treatment plans to ensure that he is addressing the individual needs of each client, and (2)including the type and frequency of services provided in the treatment plan. Program Director will be responsible for ensuring ongoing compliance with this standard through monthly chart monitors. |
709.82(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of supportive service on the treatment plans in two of the two client records.
The findings include:
Sixteen client records were reviewed on October 6-7, 2009. Four of these sixteen records were from the partial hospitalization activity. Two of those four records were required to provide the proposed type of supportive service on the treatment plan. The proposed type of supportive service was not documented on the treatment plans in client records # 11 and 12.
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Plan of Correction
The Program Director will meet with the counselor for clients #11 and #12 regarding treatment planning. Discussion/training will specifically focus on the importance of (1)individualization of treatment plans to ensure that he is addressing the individual needs of each client and (2)including proposed type of support services provided in the treatment plan. The Program Director will monitor ongoing compliance with the standard via monthly chart monitors. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on a review of client records, the facility failed to document group progress notes which contained the assessment and the plan in two of the two required records.
The findings include:
Sixteen client records were reviewed on October 6-7, 2009. Four of these sixteen records were from the partial hospitalization activity. Two of those four records were required to provide progress notes that include the assessment and the plan. Group treatment progress notes did not include the assessments of the individual's response or participation in the group session. The group treatment progress notes also failed to include the plan indicating the direction of treatment. This occurred in client records # 11 and 12.
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Plan of Correction
The Program Director will meet with the counselor for clients #11 and #12 to provide instruction and education on clinical documentation of the interactions among peers and group dynamics during each group therapy session. The Program Director will follow-up during regular supervision of the counselor involved and monitor ongoing compliance with the standard through monthly chart monitors. |
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 on a review of client records, the facility failed to document follow up attempts in three of the three required records.
The findings include:
Sixteen client records were reviewed on October 6-7, 2009. Four of these sixteen records were from the partial hospitalization activity. Three of those four records were required to document follow up attempts. Follow up attempts were not documented in client records #12, 13, and 14.
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Plan of Correction
The current policy and procedure addresses follow-up activities on all clients discharged from each level of care, regardless of status, within seven days of the appointment. The evening receptionist will be responsible for implementing the action. Program Director will ensure compliance of this standard through monthly chart monitors. |