INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21 -22, 2009 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 and a plan of correction is due on November 20, 2009.
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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, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records reviewed.
The findings include:
Four personnel records were reviewed on October 2, 2009. One personnel record was a counselor. One personnel record was required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 4.
Employee # 4 was hired on October 2, 2000. The facility training year is from January through December. The training year for January 2008 to December 2008 was reviewed. Employee # 4 only completed 12 clock hours of annual training in 2008.
The Human Resource Director confirmed on October 7, 2009 at 2:00 PM that the counselor did not have the 25 clock hours of training for the 2008 training year.
The Program Director confirmed on October 22, 2009 at 1:00 PM that the counselor did not have the 25 clock hours of training for the 2008 training year.
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Plan of Correction
Program Director will actively work with Human Resources and employees to ensure required training hours are met. Program Director will meet with all employees on a quarterly basis to review training hours, make suggestions for firther trainings, and discuss employee requests for training. First audit of trainings will be done by November 15, 2009. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document the date of completion of the discharge summary in two of four client records reviewed.
The findings include:
Five client records were reviewed on October 21-22, 2009. Discharge summaries were required to be documented in two of the client records. Discharge summaries are required to be documented within one week of discharge. Two of two discharge summaries did not include documentation of the completion date, therefore, it is unable to be determined if they were completed within the one week time frame.
Record #4 was admitted on June 10, 2009 and discharged on August 21, 2009. The discharge summary was due by August 28, 2009. The discharge summary was documented, but it did not include the date it was completed.
Record #5 was admitted on June 22, 2009 and discharged on September 18, 2009. The discharge summary was due by September 25, 2009. The discharge summary was documented, but it did not include the date it was completed.
The Program Director confirmed on October 22, 2009 at 1:00 PM that the discharge summaries did not have the date of completion documented.
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Plan of Correction
Format of discharge summary template will be changed to include the word "date" under the signature line. Counselors will be trained to include a date with their signature upon completion of the discharge summary. Changes will be made and incorporated by November 1, 2009. Program Director will monitor closed charts for 90 days to ensure changes are being incorporated. |