INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 16, 2010 licensure renewal inspection. The follow-up inspection was conducted on April 29, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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:
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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
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction.
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Plan of Correction
Employees #5, 8, 13, and 16 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. |
705.6 (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 April 28, 2011 the facility failed to ensure that the water temperature did not exceed 120 F.
The findings include:
The physical plant inspection was conducted April 28, 2011. During the tour it was found that 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.
8. Male residential client room # 219 on the third floor water temperature was 127 F.
9. Male residential client room # 221 on the third floor water temperature was 127 F.
10. Male residential client room # 226 on the third floor water temperature was 127 F.
An interviews with the facility director and maintenance director conducted on April 28, 2011 confirmed that water temperatures for sinks in the rooms exceeded 120 F.
This is a repeat citation
The facility was previously cited on November 16, 2010 for failing to ensure hot water did not exceed 120 degrees Fahrenheit.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 1/05/2011 stated the following:
"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."
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Plan of Correction
The water temperatures in the facility have been reset to 110F. The facility maintenance supervisor will complete temperature checks at least one time per month throughout the facility to ensure the water temperature does not exceed 120F. The facility director will meet with the maintenance supervisor on a monthly basis to 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, 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:
On April 28, 2011 the fire drill log was reviewed for the period covering January 2011 through April 2011. The facility failed to document whether the smoke detectors were operative or if there were any problems or issues encountered during the months of January, February, March, and April.
This was confirmed by the Facility Director and Maintenance Director.
This is a repeat citation.
The facility was previously cited on November 16, 2010 for failing to document whether the smoke detectors were operative or if there were any problems or issues encountered during fire drills.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 1/12/2011 stated the following:
"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."
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Plan of Correction
The facility director will ensure that the maintenance supervisor conducts monthly fire drills with complete and accurate documentation including the date, time, number of staff, number of clients, evacuation time, and exit routes. In addition, it will address whether emergency lights, alarms, smoke detectors and fire extinguishers were functioning properly, whether a smoke detector was set off, and whether there were any problems regarding the drill. To ensure completion, the facility director will seek-out the maintenance supervisor one week prior to the last working day of the month to ensure the drill and log were completed. |
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 interviews with the facility director and maintenance 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 April 28, 2011. The fire drill logs were reviewed from the period covering January 2011 through April 2011. Per regulation, the residential facility shall set off a fire alarm or smoke detector during each fire drill. The facility failed to specifically document in the fire drill logs that a smoke detector or fire alarm had been set off in January 2011, February 2011, March 2011 and April 2011.
An interview with the facility director and maintenance director conducted on April 28, 2010 confirmed that the facility failed to document if a smoke detector had been set off during the fire drills.
This is a repeat citation.
The facility was previously cited on November 16, 2010 for failing to set off a smoke during fire drills.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 1/12/2011 stated the following:
"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."
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Plan of Correction
The facility director will seek-out the Maintenance supervisor one week prior to the last working day of the month to ensure that he specifically documented on the fire drill logs that a smoke detector or fire alarm had been set-off during each fire drill. If this information is not specifically documented on the log the facility director will request that another fire drill be completed. This procedure will continue to occur until all documentation is properly 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 three of three partial hospitalization client records.
The findings include:
Three partial hospitalization client records were reviewed on April 28, 2011. The frequency of services were required in the individual treatment and rehabilitation plan in three client records. The facility did not document the frequency of services in the individual treatment and rehabilitation plan in client records #1, 2, and 3.
Client # 1 was admitted on February 4, 2011 and discharged on February 22, 2011. The treatment plan was completed on February 10, 2011 and did not include documentation of the frequency of treatment and rehabilitation services.
Client # 2 was admitted on March 3, 2011 and discharged on March 18, 2011. The treatment plan had a date of March 21, 2011 and did not include documentation of the frequency of treatment and rehabilitation services.
Client # 3 was admitted on March 15, 2011 and discharged on March 28, 2011. The treatment plan was completed on March 7, 2011 and did not include documentation of the frequency of treatment and rehabilitation services.
This finding was reviewed with and confirmed by the facility director.
This is a repeat citation.
The facility was previously cited on November 16, 2010 for failing to document the type and frequency of services in treatment and rehabilitation plans.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 12/22/2010 stated the following:
"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."
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Plan of Correction
All Clinical staff will receive training on the practical application of MATRS, an EBP treatment planning standard that includes correct use of frequency and durations, by 7/15/2011. Clinical supervisors will continue to review open charts on a monthly basis to ensure the type and frequency of service is noted on each plan. Program Director will review monitors to ensure completion. The treatment plan form will be modified to include a specific section for frequencies and duration. This change will occur no later than August 1, 2011 |
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 (P.H.) client records and the facility's policies and procedures, the facility failed to document case consultations in accordance with the facility's policies and procedures in two of three 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.
Three partial hospitalization client records were reviewed on April 28, 2011. Case consultations were required in three client records. The facility failed to document a case consultation within the seven day time frame in two of three partial hospitalization records.
Client # 2 was admitted to P.H. on March 3, 2011 and discharged on March 18, 2011. A case consultation had been conducted on February 24, 2011, but not since the client was admitted into P.H.
Client # 3 was admitted to P.H. on March 15, 2011 and discharged on March 28, 2011 . A case consultation had been conducted on March 10, 2011, but not since the client was admitted into P.H.
This is a repeat citation.
The facility was previously cited on November 16, 2010 for failing to document case consultations in accordance with the facility's policies and procedures.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 12/22/2010 stated the following:
"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."
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Plan of Correction
Completion of case consults will be monitored through the use of monthly open chart monitors conducted by the clinical supervisors. During weekly Clinical Staff Meetings the Clinical Supervisor for each unit will ensure that all case consults that were due from the week before are contained in each chart. |
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 seven of eight inpatient client records.
The findings include:
Eight inpatient client records were reviewed on April 28, 2011. The proposed type of support services were required in the individual treatment and rehabilitation plan in eight client records. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in client records #8, 10, 11, 12, 13, 14, and 15.
Client # 8 was admitted on April 4, 2011. The treatment plan was completed on April 5, 2011 and did not include documentation of the proposed type of support services.
Client # 10 was admitted on March 31, 2011. The treatment plan was completed on April 7, 2011 and did not include documentation of the proposed type of support services.
Client # 11 was admitted on April 1, 2011. The treatment plan was completed on April 4, 2011 and did not include documentation of the proposed type of support services.
Client # 12 was admitted on April 20, 2011. The treatment plan was completed on April 28, 2011 and did not include documentation of the proposed type of support services.
Client # 13 was admitted on March 15, 2011. The treatment plan was completed on March 16, 2011 and did not include documentation of the proposed type of support services.
Client # 14 was admitted on April 3, 2011. The treatment plan was completed on April 4, 2011 and did not include documentation of the proposed type of support services.
Client # 15 was admitted on March 31, 2011. The treatment plan was completed on April 1, 2011 and did not include documentation of the proposed type of support services.
This is a repeat citation.
The facility was previously cited on November 16, 2010 for failing to document a proposed type of support service in inpatient treatment and rehabilitation plans.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 12/22/2010 stated the following:
"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."
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Plan of Correction
The treatment plan form will be modified to include proposed support services for each client. Revision will be completed by July 15, 2011. Clinical staff will be trained on proper completion of new form by July 15, 2011. The Clinical Supervisors will monitor completion of the forms during open chart monitoring on a monthly basis. |
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 document a treatment plan update in accordance with the facility's policies and procedures in three of three inpatient client records.
Findings:
The facility policy states:
The treatment plan is updated every fourteen days 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 updated plan is reviewed with the client. The updated plan is signed by the client, the counselor, and the clinical supervisor.
Eight inpatient client records were reviewed on April 28, 2011. Three of those records required documentation of a treatment plan update. The facility did not document a treatment plan update within the specified timeframe in inpatient client records # 13, 14, and 15.
Client # 13 was admitted on March 15, 2011. The treatment plan was completed on March 16, 2011, the initial case consultation was completed on March 17, 2011. The treatment plan was updated on March 24, 2011 only.
Client # 14 was admitted on April 3, 2011. The treatment plan was completed on April 4, 2011, the initial case consultation was completed on April 1, 2011. The original treatment plan was re-dated on April 14, 2011 but did not include actual updates on the client's progress in treatment.
Client # 15 was admitted on March 31, 2011. The treatment plan was completed on April 1, 2011, the initial case consultation was completed on April 7, 2011. The treatment plan update was due on April 21, 2011 and had not been documented as of the date of inspection.
This is a repeat citation.
The facility was previously cited on November 16, 2010 for failing to document a proposed type of support service in inpatient treatment and rehabilitation plans.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 1/12/2011 stated the following:
"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."
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Plan of Correction
Clinical supervisors will monitor completion of treatment plan updates during clinical staff meetings on a weekly basis. They will also complete open chart monitors on a monthly basis to ensure treatment plan updates are being completed at the required times in accordance with Pyramid policy. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On April 29, 2011 the facility was again found to be out of compliance with the following standards:
1. 705.6 (3) The facility was previously cited on November 16, 2010 for failing to ensure hot water did not exceed 120 degrees Fahrenheit.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 1/05/2011 stated the following:
"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."
2. 705.10 The facility was previously cited on November 16, 2010 for failing to document whether the smoke detectors were operative or if there were any problems or issues encountered during fire drills.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 1/12/2011 stated the following:
"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."
3. 705.10 (d)(8) The facility was previously cited on November 16, 2010 for failing to set off a smoke during fire drills.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 1/12/2011 stated the following:
"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."
4. 709.82 (a)(2) The facility was previously cited on November 16, 2010 for failing to document the type and frequency of services in treatment and rehabilitation plans.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 12/22/2010 stated the following:
"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."
5. 709.83 (a)(4) The facility was previously cited on November 16, 2010 for failing to document case consultations in accordance with the facility's policies and procedures.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 12/22/2010 stated the following:
"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."
6. 709.52 (a)(3) The facility was previously cited on November 16, 2010 for failing to document a proposed type of support service in inpatient treatment and rehabilitation plans.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 12/22/2010 stated the following:
"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."
7. 709.52 (b) The facility was previously cited on November 16, 2010 for failing to document a proposed type of support service in inpatient treatment and rehabilitation plans.
In response to the citation issued on November 16, 2010, the facility's plan of correction submitted on 12/22/2010 and approved on 1/12/2011 stated the following:
"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."
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Plan of Correction
Program Director will monitor completion of all plans of correction. Completion will be reported to Corporate Compliance Officer as well as the Chief Operating Officer. Upon completion, all supporting documentation and evidence of changes will be reviewed by the Chief Operating Officer. A quarterly inspection of physical plant will be conducted by the Maintenance Supervisor. A quarterly review of Clinical records will be completed by the Compliance Officer to ensure completion of the clinical records. |