INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November
3 - 4,2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. - Erie Outpatient 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 3, 2009.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log, the facility failed to document monthly fire drills for two of the last twelve months.
The findings include:
The fire drill log was reviewed on November 3, 2009. The log was reviewed from November 2008 to October 2009. There was no documentation of fire drills for the months of July 2009 and August 2009. This was confirmed with the director on November 3, 2009 at 1:30 PM.
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Plan of Correction
The Risk Coordinator has begun to document the dates in that fire drills are conducted at the outpatient clinic. There will be fire drills at least once a month. This will be monitored by the Program Director at each monthly Risk Meeting. Compliance is current. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on November 3, 2009. The facility did not document which alternate exit were used during fire drills. The fire drills missing this documentation were for the months of December 2008, January 2009, February 2009, May 2009 and October 2009. This was confirmed with the director on November 3, 2009 at 1:30 PM.
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Plan of Correction
The Risk Coordinator will document alternative exits that staff and clients used for evacuation during fire drills. This will be monitored by the Program Director at monthly Risk Meetings. Compliance is current. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in two of the four required records.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Four of the fourteen client records were from the partial hospitalization activity. Four of those four records were required to have a psychosocial evaluation documented by the fifth treatment session.
Client record # 1 was admitted on 4-1-09 and discharged on 7-2-09. The client record was missing documentation of a psychosocial evaluation which was due 4-7-09. This was not documented.
Client record # 4 was admitted on 9-9-09. The client record was missing documentation of a psychosocial evaluation which was due 9-16-09. This was not documented.
The director confirmed on November 4, 2009 the records for the partial hospitalization activity did not include a psychosocial evaluation.
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Plan of Correction
Program Director scheduled a 1.0 hr. training for all clinical staff members. The training will review the timeline stating that psychosocials need completed by the 5th session. This training will also review the criteria that is required to be in the psychosocials. Each clinical staff member will develop a psychosocial that will be shared and feedback will be given to insure compliance. This training will be completed on 11/24/09. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Dec 1, 2009. |
709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan in three of the four required records.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Four of the fourteen client records were from the partial hospitalization activity. Three of those four records did not have a preliminary treatment plan documented in the first session.
Client record # 1 was admitted on 4-1-09 and discharged on 7-2-09. The client record was missing documentation of a preliminary treatment plan which was due 4-1-09. This was not documented.
Client record # 3 was admitted on 9-18-09. The client record was missing documentation of a preliminary treatment plan which was due 9-18-09. This was not documented.
Client record # 4 was admitted on 9-9-09. The client record was missing documentation of a preliminary treatment plan which was due 9-9-09. This was not documented.
The director confirmed on November 4, 2009 the records for the partial hospitalization activity did not include a preliminary treatment plan.
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Plan of Correction
Program Director scheduled 30 minutes of training for all clinical staff members. The training will review the timeline stating that preliminary treatment plans need to be completed by the first individual or group session. This training will also review the criteria required to be on the preliminary treatment plan. Each staff member will develop a preliminary treatment plan that will be shared and feedback will be given to insure compliance. This training will be completed on 11/24/09. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Dec 1, 2009 |
709.82(a) 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan in two of the four required records.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Four of the fourteen client records were from the partial hospitalization activity. Two of those four records were required to have a comprehensive treatment plan completed by the fifth session.
Client record # 1 was admitted on 4-1-09 and discharged on 7-2-09. The client record was missing documentation of a comprehensive treatment plan which was due 4-7-09. .
Client record # 3 was admitted on 9-18-09. The client record was missing documentation of a comprehensive treatment plan which was due 9-24-09.
The director confirmed on November 4, 2009 the records for the partial hospitalization activity did not document comprehensive treatment plans.
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Plan of Correction
Program Director scheduled 1 hour training for all clinical staff members. The training will review the timeline(s) stating when comprehensive treatment plan need to be completed. This training will also review the criteria required to be on the comprehensive treatment plan. Each staff member will develop a comprehensive treatment plan that will be shared and feedback will be given to insure compliance. This training will be completed on 11/24/09. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Dec 1, 2009. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in three of the three required records.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Four of the fourteen client records were from the partial hospitalization activity. Three of those four client records failed to include documentation of treatment plan updates at least every 30 days.
Client record # 1 was admitted on 4-1-09 and discharged on 7-2-09. The client record was missing documentation of a comprehensive treatment plan which was due 4-7-09. The treatment plan updates were due by 5-7-09 and 6-7-09, but neither updates were documented.
Client record # 3 was admitted on 9-18-09. The client record was missing documentation of a comprehensive treatment plan which was due 9-24-09. The treatment plan update was due 10-24-09, but was not documented.
Client record # 4 was admitted on 9-9-09. The client record included documentation of a comprehensive treatment plan which was done 9-16-09. The treatment plan update was due 10-16-09, but was not documented.
The director confirmed on November 4, 2009 the records for the partial hospitalization activity did not include a treatment plan update.
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Plan of Correction
Program Director scheduled 1 hour training for all clinical staff members. The training will review the timeline(s) stating when treatment plan updates need to be completed. This training will also review the criteria required to be on the treatment plan updates. Each staff member will develop a treatment plan updates that will be shared and feedback will be given to insure compliance. This training will be completed on 11/24/09. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Dec 1, 2009. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling at least twice weekly in two of the four client records reviewed in the partial hospitalization activity.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Four of the fourteen client records were from the partial hospitalization activity. Four of those four records were required to document individual counseling at least twice weekly. Two of those four client records did not include documentation of individual counseling at least twice weekly.
Client record # 1 was admitted on 4-1-09 and discharged on 7-2-09. The client record was missing documentation of two individual sessions per week. One individual session was completed for the weeks of April 6, 13, 20, 27, May 4 and 18. No individual sessions were documented for the weeks of May 11, June 1, 8 and 15.
Client record # 3 was admitted on 9-18-09. The client record was missing documentation of two individual sessions per week. One individual session was completed for the weeks of September 28, October 5 and 12. No individual sessions were documented for the weeks of October 19 and 26.
The director confirmed on November 4, 2009 the records for the partial hospitalization activity did not document individual counseling at least twice weekly.
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Plan of Correction
Program Director will meet with the Partial Counselor to review the standards of having two individuals per week with each client. These sessions will be scheduled on a regular basis and document in each partial chart. This review will take place 11/19/09 with the partial counselor. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Nov 23, 2009. |
709.83(a) 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement in treatment in four of the four records reviewed in the partial hospitalization activity.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Four of the fourteen client records were from the partial hospitalization activity. Four of those four records were required to have a complete client record on an individual which includes information relative to the client's involvement in treatment. Client records include client orientation and intake information, a medical history, drug and alcohol history, personal history, consent to treatment, a physical exam (if applicable), psychosocial evaluations, preliminary treatment plan, comprehensive treatment plan, treatment plan updates, Consent to release information forms, client related correspondence, case consultations, a medication record, aftercare plan (if applicable), referral contacts, record of service, progress notes, discharge summary, follow up attempt, and a termination letter (if applicable).
Client record # 1 was admitted on 4-1-09 and discharged on 7-2-09. The client record was missing documentation of a consent to treatment, psychosocial evaluation, preliminary treatment plan, comprehensive treatment plan, treatment plan updates, and follow up. The record of service did not include entries for the individual sessions. Information was disclosed without having a signed consent form allowing for the release of information.
Client record # 2 was admitted on 1-20-09 and discharged on 5-4-09. The client record was missing documentation of progress notes, an aftercare plan, a discharge summary, and a follow up attempt.
Client record # 3 was admitted on 9-18-09. The client record was missing documentation of a preliminary treatment plan, comprehensive treatment plan, treatment plan updates, and progress notes.
Client record # 4 was admitted on 9-9-09. The client record was missing documentation of a complete medical history, drug and alcohol history, personal history, psychosocial evaluations, preliminary treatment plan, comprehensive treatment plan, treatment plan updates, and a complete medication record.
The director confirmed on November 4, 2009 the records for the partial hospitalization activity were not complete.
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Plan of Correction
Program Director will meet with the Partial Counselor to review the standards of having a complete record for each client that is admitted into the clinic. This review will take place 11/19/09 with the Partial Counselor. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Nov 23, 2009. |
709.83(a)(6) 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document aftercare plans in one of one required record.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Four of the fourteen client records were from the partial hospitalization activity. One of those four records were required to document aftercare plans. Aftercare plans were not documented in one of the one required client record. In accordance with the facility policy, aftercare plans are to be completed for successful discharges.
Client record # 2 was admitted on 1-20-09 and discharged on 5-4-09. An aftercare plan was to be completed due to the client being successfully discharged. The aftercare plan was not documented.
The director confirmed on November 4, 2009 the aftercare plan for record #2 was not completed.
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Plan of Correction
Program Director will meet with the Partial Counselor to review the policy of having an aftercare plan for each client that meets criteria to develop an aftercare plan. This review will take place 11/19/09 with the Partial Counselor. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Nov 23, 2009. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes in two of the four required records.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Four of the fourteen client records were from the partial hospitalization activity. Four of those four records were required to document progress notes. Progress notes were not documented in two of the four required client records. In accordance with the facility policy, progress notes are to be completed for all clinical activity.
Client record # 2 was admitted on 1-20-09 and discharged on 5-4-09. There were no progress notes documented in this client record. The record of service indicates that services were provided to this client on January 27, 28, 29, 30; February 2, 5, 6, 9, 12, 13, 16, 20, 23, 26, 27; March 2, 5, 6, 9, 19, 26; April 2, 9, 16, 23, and 30, 2009.
Client record # 3 was admitted on 9-18-09. Progress notes were not documented in this client record where the record of service indicates that services were provided to this client on October 19, 20, 21, 22, 26, 28, 29 and 30, 2009.
The director confirmed on November 4, 2009 the progress notes were missing for client records # 2 and 3.
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Plan of Correction
Program Director will meet with the Partial Counselor to review the standard of having a progress notes for each session the client was to attend while in treatment and also the criteria that should be in the progress notes. This review will be completed with the Partial Counselor on 11/19/09. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Nov 23, 2009. |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document follow up attempts in five of the five required records.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Four of the fourteen client records were from the partial hospitalization activity. Two of those four records were required to document follow-up attempts. Follow up was not documented in two of the two required client records. Per the facility policy, follow up on clients is to be completed within seven days of discharge.
Client record # 1 was admitted on 4-1-09 and discharged on 7-2-09. The follow up attempt was due on 7-13-09. There was no documentation of the attempt.
Client record # 2 was admitted on 1-20-09 and discharged on 5-4-09. The follow up attempt was due on 5-13-09. There was no documentation of the attempt.
The director confirmed on November 4, 2009 that the follow up was not completed.
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Plan of Correction
The Program Director will meet with the Partial counselor to review the criteria for completing a follow up call with in 7 days of discharge. This review will take place on 11/19/09. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Nov 23, 2009. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document discharge summaries in two of the two required records.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Four of the fourteen client records were from the partial hospitalization activity. Two of those four records were required to document discharge summaries. Discharge summaries were not documented in one of the two required client records. The other client record did document a discharge summary but it was not dated. In accordance with facility policy, discharge summaries are to be completed within seven days of discharge.
Client record # 1 was admitted on 4-1-09 and discharged on 7-2-09. The discharge summary was due on 7-13-09. There was no documentation of the date it was completed, therefore it could not be determined if it was completed within the seven day time frame.
Client record # 2 was admitted on 1-20-09 and discharged on 5-4-09. The discharge summary was due on 5-13-09. The discharge summary was not documented.
The director confirmed on November 4, 2009 the discharge summary for record #1 was not dated, and record #2 was not completed.
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Plan of Correction
The Program Director will meet with the Partial counselor to review the criteria for completing a discharge summary for each client when they are discharge from the clinic. This review will take place on 11/19/09. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Nov 23, 2009. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document treatment plan updates in two of two client records.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Ten of the fourteen client records were from the outpatient activity. Two of the client records were required to have treatment plan updates. In accordance with the facility policy, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in client records # 6 and 9.
In client record # 6, the client was admitted on August 10, 2009. The comprehensive treatment plan was completed on August 12, 2009. A second treatment plan was completed on September 29, 2009. The first treatment plan update was due no later than October 12, 2009 and was not completed. The facility failed to document the completion of the treatment plan update.
In client record # 9, the client was admitted on August 25, 2009. The comprehensive treatment plan was completed on September 1, 2009. The first treatment plan update was due no later than November 1, 2009. The facility failed to document the completion of the first treatment plan update.
The director confirmed the treatment plan updates were not completed within the 60 day timeframe.
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Plan of Correction
Program Director scheduled 1 hour training for all clinical staff members. The training will review the timeline(s) stating when treatment plan updates need to be completed. This training will also review the criteria required to be on the treatment plan updates. Each staff member will develop a treatment plan updates that will be shared and feedback will be given to insure compliance. This training will be completed on 11/24/09. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Dec 1, 2009. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up attempts in five of the five required records.
The findings include:
Fourteen client records were reviewed on November 3 - 4, 2009. Ten of the fourteen client records were from the outpatient activity. Five of those ten records were required to document follow-up attempts. Follow up was not documented in five of the five required client records. In accordance with facility policy, follow up on clients is to be completed within seven days of discharge.
Client record # 10 was admitted on 8-10-09 and discharged on 10-5-09. The follow up attempt was due on 10-14-09 and was not documented as of 11/4/09.
Client record # 11 was admitted on 7-20-09 and discharged on 9-1-09. The follow up attempt was due on 9-11-09 and was not documented as of 11/4/09.
Client record # 12 was admitted on 7-13-09 and discharged on 8-25-09. The follow up attempt was due on 9-3-09 and was not documented as of 11/4/09.
Client record # 13 was admitted on 4-8-09 and discharged on 5-29-09. The follow up attempt was due on 6-9-09 and was not documented as of 11/4/09.
Client record # 14 was admitted on 8-31-09 and discharged on 10-20-09. The follow up attempt was due on 10-29-09 and was not documented as of 11/4/09.
The director confirmed on November 4, 2009 that the follow up was not completed.
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Plan of Correction
The Program Director will meet with all clinical staff to review the criteria for completing a follow up call with in 7 days of discharge. This review will take place on 11/20/09. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by Nov 23, 2009. |