INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18 -19, 2007 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 and a plan of correction is due on January, 25 , 2008.
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Plan of Correction
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of client records during the on site inspection held December 18 and 19, 2007 the facility failed to comply with this regulation as evidenced by documentation which indicated that the facility director supervised the counselor assistants (employee records #8 & 9). Since the facility director is not full time in the role of counselor or clinical supervisor she may not oversee the supervision of counselor assistants.
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Plan of Correction
Program Director immediately removed Counselor Assistant from the Clinical staffing grid and shifted her case load to an existing Counselor that had capacity openings on her caseload. Program Director will be responsible for the oversight of this policy and
insure that the regulation is met with future Counselor Assistants. Compliance is current.
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of client records and employee records during the on site inspection held December 18 and 19 , 2007 the facility failed to comply with this regulation as evidenced by documentation of the counselor assistant supervised period for employee # 8 and conversations with facility staff. This employee did not receive the required period of direct observation with a full time, qualified counselor or clinical supervisor present for each counseling session.
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Plan of Correction
Program Director immediately removed Counselor Assistant from direct service as a result of not being able to meet the regulation at this time. Program director is responsible for insuring that future Counselor Assistant supervision meets direct observation requirements. Compliance is current. |
704.12(b) & (c) & (d) LICENSURE Counselor Asst/Exceptions
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(b) Counselor assistants. Counselor assistants may be included in determining FTE ratios when the counselor assistant is eligible for a caseload.
(c) Exemption for transitional living. Specific client/staff ratios are not required for transitional living facilities.
(d) Exceptions. A project director may submit to the Department a written petition requesting an exception to the client/staff and client/counselor ratios in this section. The petition shall describe how the characteristics of the program and its client mix support the request for the exception and shall be approved by the governing body. Granting the petition shall be at the discretion of the Department. Long-term residential facilities and halfway houses which include a client's participation in schooling or employment as part of a treatment day are examples when requests for exceptions will be considered.
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Observations
Based on a review of client records and employee records during the on site inspection held December 18 and 19 , 2007 the facility failed to comply with this regulation as evidenced by incomplete documentation of the required period of supervision for counselor assistant # 8. The counselor assistant may not be counted in the ratio because the required period of supervision was not correctly documented.
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Plan of Correction
In response to this deficiency the Counselor Assistant was immediately removed from the ratio and capacity of the Office. Program Director reassigned Counselor Assistant's case load to a Counselor who had openings on her case load. Program Director is responsible for monitoring the ratio of each counselor to meet capacity daily. Compliance is current. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection during the on site review held December 18 and 19, 2007 the facility failed to comply with this regulation as evidenced by water temperatures in bathrooms measured at 140 degrees Farenheit.
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Plan of Correction
Program Director has met with landlord to discuss physical plant requirements for the bathrooms water temperature. Landlord has corrected the water temperature to meet regulation of 120 degrees Fahrenheit. Program Director or Risk representative will monitor water temperature monthly to insure that regulation is being met. Compliance is current. |
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 during the on site inspection held December 18 and 19, 2007 the facility failed to comply with this regulation as evidenced by treatment plan updates which were missed or lacked detail in two of three applicable client records reviewed ( #2 & 7).
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Plan of Correction
Program Director met with other Program Directors on 1/11/08 to clarify the proper way to complete PHP treatment plan updates. Program Director will complete an in house training at a staff meeting by 1/31/08 to review the training form and requirements of the regulation. Program Director will monitor compliance with monthly chart monitors.
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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 files during the on site inspection held December 18 and 19 , 2007 the facility failed to comply with this regulation as evidenced by documentation on treatment plan updates in client records # 7 & 9 ( 2 of 3 applicable records) which did not address the requirements for an assessment of client progress on the stated goals in detail.
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Plan of Correction
Program Director will train all Clinical staff on treatment plan review requirements for IOP and OPC levels of care in a staff meeting by 1/31/08. This training will also include required time frames and how to document the assessment of Clients progress on stated goals. Program director will monitor compliance with monthly chart monitors. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records during the on site inspection held December 18 and 19, 2007 the facility failed to comply with this regulation as evidenced by aftercare plans missed in client records # 10 and 13, representing two of three applicable client records. Agency policy as it addressed the formulation of aftercare plans was not followed in the client records noted.
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Plan of Correction
All policies and procedures revisions are submitted to the policy review committee through the PI Director for approval. All new or revised policies are then distributed to all program directors and reviewed at facility staff meetings. The Program Director is responsible for training all staff on the new or revised policy. The Performance Improvement Director will be responsible for the revision and the implementation of all policies. The Performance Improvement Director will immediately begin auditing program policy and procedures that address the aftercare plan policy. Policy compliance will be reviewed upon approval of the policy committee. Program Director will review process in staff meeting and monitor monthly with chart reviews.
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709.93(b) LICENSURE Client records
709.93. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
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Observations
Based on a review of client files and agency policy and procedure during the on site inspection held December 18 and 19 , 2007 the facility failed to comply with this regulation as evidenced by documentation in client records. Standardized agency forms as catalogued in the policy and procedure manual were not consistently used at this facility.
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Plan of Correction
All policies and procedures revisions are submitted to the policy review committee by the Performance Improvement Director for approval, changes and distribution. All new or revised policies are distributed to all Program Directors and reviewed at facility staff meetings. The Performance Improvement Director is responsible for the revisions and the implementation of all policies to include revisions to the standardization assessment form policy used though out the agency. The Performance Improvement Director will immediately begin auditing the standardized assessment tool policy in order to allow for alternative forms to be used when required by a governing body. Once this process has been completed Performance Improvement Director will notify Program Directors of the change so that the updated policy can be reviewed with Staff and the policy replaced in the P&P manual. |