INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. Pine Ridge 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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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain a written, informed and voluntary consent from the client that included the specific information to be disclosed and the purpose of disclosure in three of eight client records.
The findings include:
Eight client records were reviewed on September 18, 2015. Eight client records were reviewed for written, informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client that included the specific information and the purpose of disclosure in client records # 4, 6 and 8.
Client # 4 was admitted into treatment on May 27, 2015. Client # 4 signed a consent to release information form for their physician on May 27, 2015. The consent to release information form did not include the specific information to be disclosed to their physician or the purpose of the disclosure.
Client # 6 was admitted into treatment on January 6, 2015 and discharged on April 1, 2015. Client # 6 signed a consent to release information form for their employer on March 23, 2015. The consent to release information form did not include the purpose of the disclosure.
Client # 8 was admitted into treatment on January 9, 2015 and discharged on June 2, 2015. Client # 8 signed a consent to release information form for their physician on January 9, 2015. The consent to release information form did not include the specific information to be disclosed to their physician or the purpose of the disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Lead Counselors will ensure that consents are being completed properly. Program Director and lead counselors will monitor charts monthly to ensure that all consents include specific information to be disclosed and the purpose of the disclosure, and that consents are placed in the correct service category.All staff (counselors and administrative assistance) will receive a training in October on completing consents- addressing utilization of the appropriate consent and purpose and specific information to be released. Ongoing additional training will be provided as needed.
Program Director and Lead Counselors will review and audit all active client charts for accuracy of consents. New consents will be formulated as needed. |
709.53(a) LICENSURE Complete Client Record
709.53. 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
Based on a review of client records, the facility failed to document a complete client record including verification that work done by the client at the project was an integral part of his/her treatment and rehabilitation plan in seven of eight client records.
The findings include:
Eight client records were reviewed on September 18, 2015. Eight client records were reviewed for verification that work done by the client at the project was an integral part of his/her treatment plan. The facility failed to document a complete client record including verification that work done by the client at the project was an integral part of his/her treatment and rehabilitation plan in client records # 1, 3, 4, 5, 6, 7 and 8.
Client # 1 was admitted into treatment on June 2, 2015. An individual treatment plan was completed on June 8, 2015. The facility failed to document a complete client record including verification that work done by client # 1 at the project was an integral part of his/her treatment plan.
Client # 3 was admitted into treatment on June 24, 2015. An individual treatment plan was completed on July 1, 2015. The facility failed to document a complete client record including verification that work done by client # 3 at the project was an integral part of his/her treatment plan.
Client # 4 was admitted into treatment on May 27, 2015. An individual treatment plan was completed on June 3, 2015. The facility failed to document a complete client record including verification that work done by client # 4 at the project was an integral part of his/her treatment plan.
Client # 5 was admitted into treatment on November 14, 2014 and discharged on April 1, 2015. An individual treatment plan was completed on November 25, 2014. The facility failed to document a complete client record including verification that work done by client # 5 at the project was an integral part of his/her treatment plan.
Client # 6 was admitted into treatment on January 6, 2015 and discharged on April 1, 2015. An individual treatment plan was completed on January 13, 2015. The facility failed to document a complete client record including verification that work done by client # 6 at the project was an integral part of his/her treatment plan.
Client # 7 was admitted into treatment on December 12, 2014 and discharged on April 2, 2015. An individual treatment plan was completed on December 21, 2014. The facility failed to document a complete client record including verification that work done by client # 7 at the project was an integral part of his/her treatment plan.
Client # 8 was admitted into treatment on January 9, 2015 and discharged on June 2, 2015. An individual treatment plan was completed on January 15, 2015. The facility failed to document a complete client record including verification that work done by client # 8 at the project was an integral part of his/her treatment plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will include components of work therapy in each individual's treatment plan. The counselors will provide a detailed description of the work therapy that is conducted,the time frames associated with the work therapy, and the therapeutic value of participation in the work therapy. Clients will continue to be provided with detailed information on the work therapy requirements in their client handbooks for reference as well.
Counselors have been retrained on the above area and changes have begun to be implemented. Program Director and lead counselor will ensure that work therapy is identified in the treatment plan, prior to signing off on them when completed. Program Director and lead counselor will ensure all active charts are updated (including clients #1,#2, #3, and #4 who are still active). Program Director and lead counselor will continue to monitor charts monthly/randomly to ensure ongoing progress. Lead Counselors will address progress and/or ongoing concerns with counselors during their monthly supervision. Program Director and Lead Counselor will continue to educated on this area during weekly treatment team meetings. |