INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21, 2013 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.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports for the project's 14 facilities were reviewed on October 15, 2013. The project employed the equivalent of 105.275 full-time counselors, which would require the project to have at least 13 full-time clinical supervisors. The project failed to employ a full-time clinical supervisor for every eight full-time counselors as the project only employed 7 full-time clinical supervisors as of October 15, 2013.
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Plan of Correction
The Vice President of Clinical Services will ensure that the ratio of Clinical Supervisors for the project is within the defined regulation of 1 fulltime clinical supervisor for every 8 fulltime counselors or counselor assistants. The Project will re-evaluate its current system and restructure the project to include the appropriate number of clinical supervisors. Human Resources coordinators will identify the number of clinical supervisors, counselors, and counselor assistants within the system on a quarterly basis. Vice President of Clinical Services will be responsible to review staffing hours quarterly to ensure that ratio is maintained. Program Directors will notify the Vice President of Clinical Services should any changes in the ratio per site occur during the quarter. Restructuring of the Clinical Supervisor ratio will begin December 1, 2013. Clinical Supervisor ratio will be in 100% compliance by January 1, 2014. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of employee records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one employee records.
The findings include:
The facility training year runs from July 1 through June 30.
Eight employee records were reviewed on October 21, 2013. One employee record pertained to the project director and required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in employee record # 1.
Employee # 1 has been the project director since July 1, 1999. The facility failed to document 12 clock hours of annual training for employee # 1 for the July 2012 - June 2013 training year as the record only contained documentation of 10.5 hours of training.
This is repeat citation from the 2012 licensing inspection.
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Plan of Correction
Project Manager will complete 12 hours of training annually. Project Manager will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in Personnel File. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on the review of the facility's letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The facility's letters of agreement were reviewed on October 21, 2013 The letter of agreement regarding 24-hour emergency medical and psychiatric coverage expired on October 12, 2012. There was no documentation of a current letter of agreement for 24- hour emergency medical coverage.
The Facility Director was interviewed on October 21, 2013 and confirmed the findings.
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Plan of Correction
By December 31, 2013 Facility Director will submit Letters of Agreement for 24 hour emergency medical coverage to UPMC and AGH health systems after personal contact with with a person authorized to sign such an agreement. Attempts to obtain such an agreement have not yeilded a response to this point. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to document that the client was notified, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one client record.
The findings include:
Ten client records were reviewed on October 21, 2013. Four client records were reviewed as discharged clients. One client was involuntarily terminated from the project. There was no documentation that the client was notified, in writing, of a decision to involuntarily terminate the client's treatment at the project in client record # 10.
Client # 10 was admitted on February 13, 2013 and involuntarily discharged on March 22, 2013. The facility failed to provide documentation to verify that the client had been notified in writing, of a decision to involuntarily terminate the client's treatment at the project.
The Facility Director was interviewed on October 21, 2013 and confirmed the findings.
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Plan of Correction
Staff will be retrained by the Clinical Supervisor on this process by December 1, 2013. Chart monitors done by the Clinical Supervisor each month will include this item beginning with the December 2013 chart monitors. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on the review of patient records, the facility failed to document that the narcotic treatment physician determined the proper dosage level for a patient in one of two patient records.
The findings include:
Two patient records were reviewed on October 23, 2013. Two patient records required documentation that the narcotic treatment physician determined the proper dosage level for the patient. There was no documentation in client record # 3 that the narcotic treatment physician determined the proper dosage level for the patient.
Patient # 3 was admitted on September 25, 2013. The patient received an initial dose of 2 mgs of suboxone. There was no documentation provided that the narcotic treatment physician had determined the dosage for patient # 3.
The Facility Director was interviewed on October 23, 2013 and confirmed the findings.
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Plan of Correction
Since the review date, all of the Suboxone records have been reviewed and corrected. The Physician and the Nurse have structured a process to ensure documentation is completed and correct. This process began immediately on November 4, 2013. The plan for the future is begin the use of the electronic clinical record with the Suboxone clients although the timeline is not yet set for this to happen. This use will include alerts on documentation that is due. The narcotic treatment physician will determine and document validation and correct dose. Ten charts will be monitored each month beginning with November 2013. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan that included short and long-term treatment goals in three of three client records.
The findings include:
Ten client records were reviewed on October 21, 2013. Three client records were reviewed as outpatient client records. Three client records required treatment plans that included short and long-term treatment goals. The facility failed to document short and long-term treatment goals on individual treatment plans contained in client records # 1, 2 and 4.
Client # 1 was admitted on April 22, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on May 6, 2013, did not include documentation of short and long-term treatment goals.
Client # 2 was admitted on July 11, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on July 15, 2013, did not include documentation of short and long-term treatment goals.
Client # 4 was admitted on May 1, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on May 1, 2013, did not include documentation of short and long-term treatment goals.
The Facility Director was interviewed on October 21, 2013 and did not dispute the findings.
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Plan of Correction
All clinical staff will be re trained on the elements of MATRS treatment planning which includes identifying long and short term goals with specific interventions by January 1, 2014. Clinical Supervisor will monitor the appropriate completion of treatment plans through monthly open chart monitors. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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 an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services in three of three client records.
The findings include:
Ten client records were reviewed on October 21, 2013. Three client records were reviewed as outpatient client records. Three client records required individual treatment plans that included the type and frequency of treatment and rehabilitation services . The facility failed to document the type and frequency of treatment and rehabilitation services on individual treatment plans contained in client records # 1, 2 and 4.
Client # 1 was admitted on April 22, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on May 6, 2013, did not include the type and frequency of treatment and rehabilitation services.
Client # 2 was admitted on July 11, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on July 15, 2013, did not include the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on May 1, 2013. The individual treatment and rehabilitation plan, signed by the client and staff on May 1, 2013, did not include the type and frequency of treatment and rehabilitation services.
The Facility Director was interviewed on October 21, 2013 and did not dispute the findings.
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Plan of Correction
Electronic medical record was implemented recently that includes a designated tab for documenting type and frequency in the treatment plan. Completion of Treatment plan will be reviewed with clinical staff in staff meeting by December 1, 2013. Clinical Supervisor will monitor the completion of treatment plan, including type and frequency, through the use of open chart monitors. |
709.93(a) LICENSURE Client records
709.93. 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 the review of client records, the facility failed to document a complete client record that included case consultation notes in three of three client records and follow-up information in one of two client records.
The findings include:
Ten client records were reviewed on October 21, 2013. Five client records were reviewed as outpatient clients, two of which were discharged clients. Three client records required case consultation notes. The facility failed to document case consultation notes in client records # 1, 2 and 4. Two client records required documentation of follow-up information within 7 days of discharge. The facility failed to document follow-up information in client record # 10.
Client # 1 was admitted on April 23, 2013. The facility failed to provide documentation that a case consultation had been completed as of October 21, 2013.
Client # 2 was admitted on July 11, 2013. The facility failed to provide documentation that a case consultation had been completed as of October 21, 2013.
Client # 4 was admitted on May 1, 2013 and a case consultation note was due to be completed by September 30, 2013. The facility failed to provide documentation that a case consultation had been completed as of October 21, 2013.
Client # 10 was admitted on February 13, 2013 and discharged on March 22, 2013. Follow-up was to be completed by March 29, 2013. The facility failed to provide documentation of follow-up information as of October 21, 2013.
The Facility Director was interviewed on October 21, 2013 and confirmed the findings.
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Plan of Correction
Designated staff responsible for completing follow up calls will be re trained on the follow up call process by December 15, 2013. Program Director and Clinical Supervisor will monitor completion of follow calls through closed chart monitors monthly. |