INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15 through 16, 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 December 28, 2010.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report the facility failed to ensure that each counselor completed at least 25 clock hours of training per year.
The findings include.
Eighteen personnel records were reviewed on November 16, 2010 inspection; eleven of which were those of counselors and required 25 documented clock hours of training per year. According to the Staffing Requirements Facility Summary Report, the facility training year runs from January 1, 2009 to December 31, 2009. The facility failed to ensure employees # 5, 8, 13, and 16 had 25 training hours for the 2009 training year.
Employee # 5 was hired as a counselor on March 25, 2001. Employee # 3 had only 21 documented clock hours of training during January 1, 2009 through December 31, 2009.
Employee # 8 was hired as a counselor on February 18, 2008. Employee # 8 had only 24 documented clock hours of training during January 1, 2009 through December 31, 2009.
Employee # 13 was hired as a counselor on September 5 2008. Employee # 13 had only 19 documented clock hours of training during January 1, 2009 through December 31, 2009.
Employee # 16 was hired as a counselor on May 12, 2008. Employee # 16 had only 19 documented clock hours of training during January 1, 2009 through December 31, 2009.
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Plan of Correction
Employees #5,8,13, and 16 have completed the required training hours for 2010. To ensure this deficiency does not recur for both the referenced employees and other staff, the Pyramid Human Resources Director will perform training audits on a quarterly basis and mandate under threat of disciplinary action, that the required hours of training be completed between January and December of each calendar year. This will begin by 4/1/11. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a tour of the physical plant and an interview with the maintenance director, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A tour of the facility was conducted on November 16, 2010. During the tour, at approximately 9:40 AM, both of the outside dumpsters were only partially covered with lids.
An interview with the maintenance director conducted on November 16, 2010 confirmed that the dumpsters were only partially covered with lids. However, during the tour, the maintenance director fully covered the dumpsters with lids.
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Plan of Correction
An alternate type of dumpsters will be obtained by the Maintenance Director that will allow for easier access and consistent coverage with lids. To ensure this deficiency does not reoccur the facility Maintenance Supervisor will monitor the dumpsters on a weekly basis and report any issues to the Maintenance Director. This will be completed by 1/31/11. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a tour of the physical plant and an interview with two of the detox after care specialists, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
The findings include:
A tour of the facility was conducted on November 16, 2010. During the tour, at approximately 1:40 PM, it was observed that the detox after care room is made in such a way that two clients can receive individual counseling sessions at the same time. Also, it was observed that the detox after care room is made in such a way in which clients ' counseling sessions can be seen and heard. In addition, it was observed that that the detox after care room has a copier machine in which people can freely come in and out of the room to use the copier machine.
An interview with two of the detox after care specialists conducted on November 16, 2010 confirmed that clients ' counseling sessions can be seen and heard in the detox after care room.
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Plan of Correction
An alternate space will be provided for the Detox Aftercare Specialists when it is necessary for them to meet with more than one client at a time. The alternate spaces to be utilized will be the Detox Counselor's Office, the doctor's office located beside the Nurses' Station, and the Nursing Secretary Supervisor's Office located in the Detox Wing of the facility. The Detox Specialists will be responsible to move to one of these alternate locations if another client is in the Detox Aftercare Specialist's Office. This will begin by 12/31/10. The Detox Program Director will monitor this process to ensure privacy is provided. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observations on November 16, 2010 the facility failed to ensure that the water temperature did not exceed 120 F in 18 of 25 rooms reviewed.
The findings include:
The physical plant inspection was conducted November 16, 2010. On November 16, 2010 temperatures for 2 sinks in the men's rest-room near kitchen, 1 male public restroom, 1 female public restroom on the first floor, and 13 residential client rooms were taken. Also, on November 16, 2010 temperatures for sinks in 5 male detox unit rooms and 4 female detox unit rooms were taken.
1. The male's public restroom on the first floor water temperature was 130 F.
2. The female's public restroom on the first floor water temperature was 123 F.
3. Female residential client room # 112 on the second floor water temperature was 135 F.
4. Female residential client room # 114 on the second floor water temperature was 140 F.
5. Female residential client room # 117 on the second floor water temperature was 128 F.
6. Female residential client room # 116 on the second floor water temperature was 129 F.
7. Female residential client room # 118 on the second floor water temperature was 135 F.
8. Male residential client room # 219 on the third floor water temperature was 138 F.
9. Male residential client room # 221 on the third floor water temperature was 136 F.
10. Male residential client room # 226 on the third floor water temperature was 132 F.
11. Male residential client room # 226 on the third floor water temperature was 132 F.
12. Male detox unit room # B 3 on the first floor water temperature was 124 F.
13. Male detox unit room # B 4 on the first floor water temperature was 124 F.
14. Male detox unit room # B 5 on the first floor water temperature was 124 F.
15. Male detox unit room # B 7 on the first floor water temperature was 125 F.
16. Female detox unit room # B 11 on the first floor water temperature was 125 F.
17. Female detox unit room # B 13 on the first floor water temperature was 124 F.
18. Female detox unit room # B 15 on the first floor water temperature was 125 F.
An interview with the facility director and maintenance director conducted on November 16, 2010 confirmed that water temperatures for sinks in the rooms exceeded 120 F.
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Plan of Correction
Mixing valves have been installed in all water heaters within the facility. As a result, hot water temperatures will no longer exceed 120 F at any time. The facility maintenance worker will complete temperature checks at least one time per month throughout the facility to determine whether the mixing valves are working correctly and to ensure the temperature does not exceed 120 F. The Maintenance Supervisor will monitor and ensure completion of the checks. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based upon a review of the facility's fire drill record on November 15 and 16, 2010, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and/or whether the fire alarm or smoke detector was operative.
The findings include:
The facility failed to document the evacuation times and the exit routes used for the fire drills conducted during June, July , August, September and October. The facility failed to document if the smoke detectors were operative during the months of August and October. In addition the facility failed to document any problems, issues or acknowledgements for the months of August and October.
This was confirmed by the Facility Director.
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Plan of Correction
The facility Director will ensure that the facility Maintenance Supervisor will conduct monthly fire drills with complete and accurate documentation including the date, time, the amount of time taken to evacuate, exit routes used, number of persons in the building, problems encountered, and whether fire alarms/smoke detectors are operative. To ensure completion on a monthly basis, the Maintenance Supervisor will submit a copy of the completed log to the Facility Director within 24 hours of the completed monthly fire drills. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs and an interview with the facility director, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on November 16, 2010. Per regulation, the residential facility shall set off a fire alarm or smoke detector during each fire drill. The facility failed to specifically document on the fire drill logs that a smoke detector or fire alarm had been set off on August 2010 through October 2010.
An interview with the facility director and maintenance director conducted on November 16, 2010 confirmed that the facility failed to specifically document on the fire drill logs.
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Plan of Correction
The Maintenance Supervisor will provide a copy of the completed fire drill log to the facility Director within 24 hours after the monthly drill. The facility Director will ensure that the facility Maintenance Supervisor specifically documents on the fire drill logs that a smoke detector or fire alarm had been set-off during each fire drill. If it is not specifically documented in the log that a smoke detector or fire alarm had been set-off the facility Director will request that another unscheduled fire drill occur. This procedure will take place until all documentation is completed. |
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 the review of client records, the facility failed to document the frequency of services in the individual treatment and rehabilitation plan in four of five partial hospitalization client records.
The findings include:
Five partial hospitalization client records were reviewed on November 15 through 16, 2010. The frequency of services were required in the individual treatment and rehabilitation plan in ten client records. The facility did not document the frequency of services in the individual treatment and rehabilitation plan in client records #18, 19, 20, and 21.
Client # 18 was admitted on October 28, 2010. The treatment plan was completed on November 4, 2010 and did not include documentation of the frequency of treatment and rehabilitation services.
Client # 19 was admitted on October 20, 2010. The treatment plan was completed on October 26, 2010 and did not include documentation of the frequency of treatment and rehabilitation services.
Client # 20 was admitted on October 7, 2010. The treatment plan was completed on October 14, 2010 and did not include documentation of the frequency of treatment and rehabilitation services.
Client # 21 was admitted on April 12, 2010. The treatment plan was completed on April 12, 2010 and did not include documentation of the frequency of treatment and rehabilitation services.
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Plan of Correction
The Program Director will meet with the Counselor of clients # 18, 19 and 20 regarding treatment planning. The Clinical Supervisor will meet with the Counselor for client #21 regarding treatment planning. The discussions will specifically focus on the importance of including the type and frequency of services provided in the treatment plan. The Program Director for the Counselor of clients #18, 19 and 20 and the Clinical Supervisor of the Counselor for client #21 will monitor ongoing compliance with the standard via monthly supervision and monitoring of client charts. |
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 the review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in four of five partial hospitalization client records.
The findings include:
Five partial hospitalization client records were reviewed on November 15 through 16, 2010. The proposed type of support services were required in the individual treatment and rehabilitation plan in five client records. The facility did not document the proposed support services in the individual treatment and rehabilitation plan in client records #18, 19, 20, and 21.
Client # 18 was admitted on October 28, 2010. The treatment plan was completed on November 4, 2010 and did not include documentation of the proposed support services.
Client # 19 was admitted on October 20, 2010. The treatment plan was completed on October 26, 2010 and did not include documentation of the proposed support services.
Client # 20 was admitted on October 7, 2010. The treatment plan was completed on October 14, 2010 and did not include documentation of the proposed support services.
Client # 21 was admitted on April 12, 2010. The treatment plan was completed on April 12, 2010 and did not include documentation of the frequency of proposed support services.
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Plan of Correction
The facility Program Director will meet with the Counselor of clients #18, 19, and 20 regarding treatment planning. The Clinical Supervisor will meet with the Counselor of client #21. Discussions will specifically focus on including the proposed type of support services provided in the treatment plan. The Program Director and Clinical Supervisor will monitor ongoing compliance with the standard through monthly chart monitors. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on the review of partial hospitalization client records and the facility's policies and procedures, the facility failed to document case consultations four of five partial hospitalization client records
The findings include:
The facility's policy states, case consultations shall be completed within seven days and every 90 days thereafter. The case consultation shall be signed by the counselor and the clinical supervisor.
Five partial hospitalization client records were reviewed on November 15 through November 16, 2010. Case consultations were required in five client records. The facility failed to include the signature of the clinical supervisor in client records # 18, 19, 20, and 21.
Client # 18 was admitted on October 28, 2010. A case consultation had been conducted on November 4, 2010 and did not include the signature of the clinical supervisor.
Client # 19 was admitted on October 20, 2010. A case consultation had been conducted on October 21, 2010 and did not include the signature of the clinical supervisor.
Client # 20 was admitted on October 7, 2010. A case consultation had been conducted on October 14, 2010 and did not include the signature of the clinical supervisor.
Client # 21 was admitted on April 12, 2010. A case consultation had been completed but was undated and unsigned.
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Plan of Correction
On the date the consultation is due the Program Director and the Counselor will meet, the written consultation will be completed, and both will sign-off on the Case Consultation form. On the eighth day after a Partial client's admission the Program Director will review the open chart to ensure it contains a completed Case Consultation form. The facility Program Director will meet with the counselor for clients #18, 19, 20, and 21 to ensure this process occurs. This will begin by 1/1/11. |
709.63(a)(5) LICENSURE Record of Services
709.63. 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) Record of services provided.
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Observations
Based on a review of patient records, the facility failed to document a record of services provided in seven of seven detox patient records.
Findings:
Seven detox patient records were reviewed on November 15 through 16, 2010. Seven records required a documented record of services provided. The facility did not document a record of service provided in detox records # 1, 2, 3, 4, 5, 6, and 7.
Patient # 1 was admitted on November 10, 2010. As of the date of inspection there was no record of services provided in record #1.
Patient # 2 was admitted on November 10, 2010. As of the date of inspection there was no record of services provided in record #2.
Patient # 3 was admitted on November 12, 2010. As of the date of inspection there was no record of services provided in record #3.
Patient # 4 was admitted on November 11, 2010. As of the date of inspection there was no record of services provided in record #4.
Patient # 5 was admitted on November 10, 2010. As of the date of inspection there was no record of services provided in record #5.
Patient # 6 was admitted on September 28, 2010 and discharged on October 1, 2010. As of the date of inspection there was no record of services provided in record #6.
Patient #7 was admitted on September 19, 2010 and discharged on September 24, 2010. As of the date of inspection there was no record of services provided in record #7.
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Plan of Correction
A Detox Record of Service will be completed on each client and placed in the client file. The Detox Program Director will ensure these are being consistently completed by adding the item to the Closed Chart Monitors which are completed on a monthly basis. |
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 15 through 16, 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 # 8 was admitted on September 16, 2010. The treatment plan was completed on September 17, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services.
Client # 9 was admitted on October 5, 2010. The treatment plan was completed on October 6, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services.
Client # 10 was admitted on October 7, 2010. The treatment plan was completed on October 14, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services.
Client # 11 was admitted on October 1, 2010. The treatment plan was completed on October 8, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services.
Client # 12 was admitted on September 24, 2010. The treatment plan was completed on September 27, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services.
Client # 13 was admitted on September 3, 2010. The treatment plan was completed on September 6, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services.
Client # 14 was admitted on September 8, 2010. The treatment plan was completed on September 9, 2010 and did not include documentation of the type and frequency treatment and rehabilitation services.
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Plan of Correction
The Clinical Supervisors will meet with the Counselors of clients #8, 9, 10, 11, 12, 13, and 14 regarding treatment planning. Discussions will specifically focus on the importance of including the type and frequency of services provided in the treatment plan. The Clinical Supervisors for counselors who counseled clients #8, 9, 10, 11, 12, 13, and 14 will monitor ongoing compliance with the standard via monthly supervision and chart monitors. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in six of ten inpatient client records.
The findings include:
Ten outpatient client records were reviewed on November 15 through 16, 2010. The proposed type of support services were required in the individual treatment and rehabilitation plan in ten client records. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in client records #10, 11, 12, 13, 14, and 17.
Client # 10 was admitted on October 7, 2010. The treatment plan was completed on October 14, 2010 and did not include documentation of the proposed type of support services.
Client # 11 was admitted on October 1, 2010. The treatment plan was completed on October 8, 2010 and did not include documentation of the proposed type of support services.
Client # 12 was admitted on September 24, 2010. The treatment plan was completed on September 27, 2010 and did not include documentation of the proposed type of support services.
Client # 13 was admitted on September 3, 2010. The treatment plan was completed on September 6, 2010 and did not include documentation of the proposed type of support services.
Client # 14 was admitted on September 8, 2010. The treatment plan was completed on September 9, 2010 and did not include documentation of the proposed type of support services.
Client # 17 was admitted on July 13, 2010. The treatment plan was completed on July 15, 2010 and did not include documentation of the proposed type of support services.
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Plan of Correction
The facility Clinical Supervisors will meet with the Counselors for clients #10, 11, 12, 13, 14, and 17. Discussions will specifically focus on the importance of including proposed type of support services within the treatment plan. This will be monitored by the Clinical Supervisors through completion of monthly chart monitors. |
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 on a review of client records and the facility's policies and procedures, the facility failed to timely document a treatment plan update in six of ten inpatient client records.
Findings:
The facility policy states:
The treatment plan is updated weekly after the initial case consultation for the adult short-term residential program. The assigned counselor documents progress on or attainment of goals and the need for revisions or modification of strategy. The update plan is reviewed with the client. The updated plan is signed by the client, the counselor, and the clinical supervisor.
Ten client records requiring treatment plan updates were reviewed on November 15 and November 16, 2010. The facility did not document a treatment plan update weekly after the case consultation in outpatient client records # 8, 9, 10, 12, 13, and 17.
Client # 8 was admitted on September 16, 2010. The treatment plan was completed on September 17, 2010, the initial case consultation was completed on September 30, 2010. The treatment plan was updated on 9/30/10 and 10/28/10 only.
Client # 9 was admitted on September 8, 2010. The treatment plan was completed on September 9, 2010, the initial case consultation was completed on October 6, 2010. The treatment plan was updated on 10/14/10 and 11/11/10 only.
Client # 10 was admitted on October 7, 2010. The treatment plan was completed on October 14, 2010, the initial case consultation was completed on October 13, 2010. The treatment plan was updated on 10/21/10 only.
Client # 12 was admitted on September 24, 2010. The treatment plan was completed on September 27, 2010, the initial case consultation was completed on September 30, 2010. The treatment plan was updated on 10/28/10 only.
Client # 13 was admitted on September 3, 2010 and discharged on September 27, 2010. The treatment plan was completed on September 6, 2010, the initial case consultation was completed on September 9, 2010. The treatment plan was updated on 9/7/10 and 9/10/10 only.
Client # 17 was admitted on July 13, 2010 and discharged on September 17, 2010. The treatment plan was completed on July 15, 2010, the initial case consultation was completed on July 22, 2010. The treatment plan was updated on 8/19/10 only.
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Plan of Correction
Pyramid's Director of Clinical Services will make changes to the Policy and Procedure Manual to reflect that, for clients whose treatment regime is less than 30 days, updates and reviews will be completed every 14 days. The facility's Clinical Supervisors will ensure counselors' adherence to this policy by completing monthly Open and Closed Chart Monitors. This will begin by 1/1/11. |