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 3 - 4, 2009 licensure renewal inspection. The follow-up inspection was conducted on January 28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 February 26, 2010.
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Plan of Correction
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705.24 (6) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant tour on January 28, 2010 at 10:30 AM, the facility failed to provide toilet paper in the woman's restroom.
The findings include:
The woman's restroom did not have toilet paper at 10:30 AM. When the restroom was entered again at approximately 2:30 PM, there was minimal toilet paper available. The director confirmed that continues to be a problem with the landlord.
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Plan of Correction
Staff will continue to notify the program director when the bathroom facilities are in need of maintenance. The director will also notify the landlord in problems occur along with having a backup supply in the front office. Compliance will be by March 1, 2010 |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant tour on January 28, 2010 at 10:30 AM, the facility director's office included a heater that was not permanently mounted or installed.
The findings include:
The director's office included a heater that was not permanently mounted or installed. The director confirmed that regulating the temperature continues to be a problem with the landlord.
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Plan of Correction
The heating system does not work correctly throughout the facility and numerous reports have been made to the Landlord but have not been fixed. There will not be heaters that are installed properly. Compliance will be by March 1, 2010 |
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 two required records.
The findings include:
Due to this survey being an unannounced plan of correction follow-up visit, the time frame for the record review was limited. The date of correction noted on the plan of correction was December 1, 2009. So the client record review was from December 1, 2009 to the date of this survey on January 28, 2010. Ten client records were reviewed on January 28, 2010. Four of the ten client records were from the partial hospitalization activity. Two of those four records were required to have a psychosocial evaluation documented by the fifth treatment session. One client record was missing the psychosocial evaluation. One record did not include an evaluation of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
Record # 3 was admitted on 12-7-09. The client record was missing documentation of a psychosocial evaluation which was due 12-11-09. This was not documented.
Record # 4 was admitted on 1-6-10. The client record did document a psychosocial evaluation on 12-31-09, but the evaluation did not provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
The director confirmed on January 28, 2010 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 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 during the staff members individual sessions by 2/15/2010. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. Compliance will be by March 1, 2010 |
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 one of the two required records.
The findings include:
Due to this survey being an unannounced plan of correction follow-up visit, the time period for the record review was limited. The date of correction noted on the plan of correction was December 1, 2009. So the client record review was from December 1, 2009 to the date of this survey on January 28, 2010. Ten client records were reviewed on January 28, 2010. Four of the ten client records were from the partial hospitalization activity. Two of those four records were required to include documentation of a comprehensive treatment plan completed by the fifth session.
Record # 4 was admitted on 1-6-10. The client record was missing documentation of a comprehensive treatment plan which was due 1-13-10.
The director confirmed on January 28, 2010 the record was missing a a comprehensive treatment plan.
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Plan of Correction
Program Director scheduled an individual 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 2/15/2010. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. |
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 two records reviewed in the partial hospitalization activity.
The findings include:
Due to this survey being an unannounced plan of correction follow-up visit, the time frame for the record review was limited. The date of correction noted on the plan of correction was December 1, 2009. So the client record review was from December 1, 2009 to the date of this survey on January 28, 2010. Ten client records were reviewed on January 28, 2010. Four of the ten client records were from the partial hospitalization activity. Two of those four records were required to have individual counseling, at least twice weekly.
Record # 3 was admitted on 12-7-09. The client record was missing documentation of two individual sessions per week. One individual session was completed for the week of December 21. No individual sessions were documented for the weeks of December 14, December 28, January 4, 11, 18 and 25.
Record # 4 was admitted on 1-6-10. The client record was missing documentation of two individual sessions per week. No individual sessions were documented for the weeks of January 11, 18 and 25.
The director confirmed on January 28, 2010 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 by 2/19/2010 with the partial counselor. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. |
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 two of the two records reviewed in the partial hospitalization activity.
The findings include:
Due to this survey being an unannounced plan of correction follow-up visit, the time frame for the record review was limited. The date of correction noted on the plan of correction was December 1, 2009. So the client record review was from December 1, 2009 to the date of this survey on January 28, 2010. Ten client records were reviewed on January 28, 2010. Four of the ten client records were from the partial hospitalization activity. Two of those four records were required to have a complete client record on an individual which includes information relative to the client's involvement. 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, client related correspondence, case consultations, a medication record, aftercare plan (if applicable), referral contacts, record of service, progress notes, discharge summary, follow up attempt, termination letter (if applicable).
Record # 3 was admitted on 12-7-09. The client record was missing documentation of a
psychosocial evaluation and group progress notes.
Record # 4 was admitted on 1-6-10. The client record was missing documentation of a comprehensive treatment plan and group progress notes.
The director confirmed on January 28, 2010 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 by 2/16/2010 with the Partial Counselor. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. |
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 include documentation of aftercare plans. Aftercare plans were not documented in one of the one required client records. Per the facility policy, aftercare plans are to be completed for successful discharges.
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.
January 28, 2010 - Due to this survey being an unannounced plan of correction follow-up visit, the time frame for the record review was limited. The date of correction noted on the plan of correction was December 1, 2009. So the client record review was from December 1, 2009 to the date of this survey on January 28, 2010. Ten client records were reviewed on January 28, 2010. Four of the ten client records were from the partial hospitalization activity. The time frame of observation was insufficient to determine compliance. The facility should re-submit the original plan of correction.
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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 in an individual session on 2/15/2010 with the Partial Counselor. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. |
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 two required records.
The findings include:
Due to this survey being an unannounced plan of correction follow-up visit, the time frame for the record review was limited. The date of correction noted on the plan of correction was December 1, 2009. So the client record review was from December 1, 2009 to the date of this survey on January 28, 2010. Ten client records were reviewed on January 28, 2010. Four of the ten client records were from the partial hospitalization activity. Two of those four records were required to document progress notes. Per the facility policy, progress notes are to be completed for all clinical activity.
Record # 3 was admitted on 12-7-09. The record of service indicates that services were provided to this client on January 7, 8, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22 and 25, 2009. Progress notes are not documented for the group sessions documented on the record of service.
Record # 4 was admitted on 1-6-10. The record of service indicates that services were provided to this client on January 7, 8, 12, 13, 14, 15, 18, 19, 20, 21, 22 and 25, 2009. Progress notes are not documented for the group sessions documented on the record of service.
The director confirmed on January 28, 2010 the progress notes were missing for client records.
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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 2/15/2010. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. |
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 discharge summaries in two of the two records reviewed.
The findings include:
Due to this survey being an unannounced plan of correction follow-up visit, the time frame for the record review was limited. The date of correction noted on the plan of correction was December 1, 2009. So the client record review was from December 1, 2009 to the date of this survey on January 28, 2010. Ten client records were reviewed on January 28, 2010. Four of the ten client records were from the partial hospitalization activity. Two of those four records were required to document a discharge summary. In accordance with the facility policy, discharge summaries are to be completed within seven days of discharge.
Client record #1 - Client was admitted on 11-27-09 and discharged on 12-3-09. Client only attended one session on 11-27-09. The discharge summary was due by 12-14-09. The discharge summary was not documented.
Client record # 2 - Client was admitted on 11-30-09. The client attended only one session on 11-30-09. The discharge date was not documented. Per the director, the discharge date was either 12-4-09 or 12-7-09. The discharge summary was not documented.
The director confirmed on January 28, 2010 that the discharge summaries were not documented.
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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 during an individual session on 2/15/2010. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. |
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 follow up attempts in two of the two records reviewed.
The findings include:
Due to this survey being an unannounced plan of correction follow-up visit, the time frame for the record review was limited. The date of correction noted on the plan of correction was December 1, 2009. So the client record review was from December 1, 2009 to the date of this survey on January 28, 2010. Ten client records were reviewed on January 28, 2010. Four of the ten client records were from the partial hospitalization activity. Two of those four records were required to document follow up attempts. In accordance with the facility policy, follow up attempts on clients are to be completed within seven days of discharge.
Client record #1 - Client was admitted on 11-27-09 and discharged on 12-3-09. The follow up attempt was due by 12-14-09. The follow up attempt was not documented.
Client record # 2 - Client was admitted on 11-30-09. The client attended only one session on 11-30-09. The discharge date was not documented. Per the director, the discharge date was either 12-4-09 or 12-7-09. A follow up attempt was not documented.
The director confirmed on January 28, 2010 that follow up attempts were not documented.
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Plan of Correction
The Program Director will meet with the counselor to review the criteria for completing a follow up call with in 7 days of discharge. This review will take place on 2/18/2010. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. |
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 three client records.
The findings include:
Due to this survey being an unannounced plan of correction follow-up visit, the time frame for the record review was limited. The date of correction noted on the plan of correction was December 1, 2009. So the client record review was from December 1, 2009 to the date of this survey on January 28, 2010. Ten client records were reviewed on January 28, 2010. Six of the ten client records were from the outpatient activity. Three of those six records were required to include documentation of a treatment plan update. Per 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 # 9 and 10. One client record did provide a treatment plan update.
In client record # 9, the client was admitted on 10-7-09. The comprehensive treatment plan was completed on 10-19-09. The first treatment plan update was due no later than
12-19-09 and was not completed. The facility failed to document the completion of the treatment plan update.
In client record # 10, the client was admitted on 10-30-09. The comprehensive treatment plan was completed on 11-6-09. The first treatment plan update was due no later than 1-6-10. The facility failed to document the completion of the 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 individual 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 2/15/2010. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. |
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 three of the three required records.
The findings include:
Due to this survey being an unannounced plan of correction follow-up visit, the time frame for the record review was limited. The date of correction noted on the plan of correction was December 1, 2009. So the client record review was from December 1, 2009 to the date of this survey on January 28, 2010. Ten client records were reviewed on January 28, 2010. Six of the ten client records were from the outpatient activity. Three of those six records were required to document a follow up attempt.
Record # 5 was admitted on 10-22-09 and discharged on 12-7-09. The follow up attempt was due on 12-16-09.
Record # 6 was admitted on 12-8-09 and discharged on 12-21-09. The follow up attempt was due on 12-31-09.
Record # 7 was admitted on 11-16-09 and discharged on 12-7-09. The follow up attempt was due on 12-16-09.
The director confirmed on January 28, 2010 that the follow-up attempt 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 2/15/2010. The Program Director will also monitor compliance through monthly chart monitors of active and discharge charts. |