INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 18 -19, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc - Transitions 2, 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 16, 2010.
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on a review of personnel records on October 4, 2010, and a conversation with the director on October 18-19, 2010, the clinical supervisor failed to complete a core curriculum training in clinical supervision.
The findings include:
Personnel record #7 was hired by the facility on April 28, 2008 and promoted to clinical supervisor on May 25, 2009. As of the date of the personnel record review on October 4, 2010 and the date of the conversation with the director on October 18-19, 2010, employee #7 failed to complete a core curriculum training in clinical supervision.
|
Plan of Correction
Clinical Supervisor will be registered to complete Clinical Supervision training prior to her 2 years as Clinical Supervisor, March 23, 2011. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel records, a review of the facility summary report, and a conversation with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training for eight of ten personnel/training records.
The findings include:
Sixteen personnel records were reviewed on October 1 and 4, 2010. The facility summary report was reviewed on October 18-19, 2010. Ten personnel were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for personnel records # 8, 9, 10, 11, 12, 13, 14 and 15.
Employee # 8 is a support staff and was hired August 11, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by August 11, 2009. The facility failed to provide documentation of TB/STD training.
Employee # 9 is a support staff and was hired April 11, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by April 11, 2010. The facility failed to provide documentation of TB/STD training.
Employee #10 is a support staff and was hired January 4, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by January 4, 2010. The facility failed to provide documentation of TB/STD training.
Employee #11 is a support staff and was hired August 25, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by August 25, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
Employee #12 is a support staff and was hired August 10, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by August 10, 2010. The facility failed to provide documentation of TB/STD training.
Employee #13 is a support staff and was hired July 18, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by July 18, 2009. The facility failed to provide documentation of TB/STD training.
Employee #14 is a support staff and was hired October 24, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by October 24, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training.
Employee #15 is a support staff and was hired February 22, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by February 22, 2010. The facility failed to provide documentation of TB/STD training.
|
Plan of Correction
Employees will be registered to complete necessary trainings within the next 90 days, no later than 2/15/2011. Program Director will monitor to ensure compliance. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in six of eight client records.
The findings include:
Ten client records were reviewed on October 18 - 19, 2010. Eight client records were reviewed for the requirement to include an informed and voluntary consent from the client prior to the disclosure of information. Six of the eight client records, #1, 2, 3, 8, 9 and 10 did not include completed consents prior to the disclosure of information.
Client record #1 included a release of information form to a referral source that did not include the specific information to be disclosed. The specific information section on the release of information form was blank. This client record also included a release of information form to an insurance company that did not include the purpose of the disclosure. The purpose section on the form was blank. This form was signed by client and the staff member on 10-15-10. The admission date for this client was 10-14-10.
Client record #2 included a release of information to the primary care physician that did not include the specific information to be disclosed. The specific information section on the release of information form was blank. This was signed by client and the staff member on 10-13-10. The admission date for this client was 10-13-10.
Client record #3 included a release of information form to a criminal justice agency that did not include the specific information to be disclosed. The specific information section on the release of information form was blank. In addition, this same release of information form did not include the purpose of the disclosure. The purpose section on the form had "other" indicated, but the the explanation for other was blank. The admission date for this client was 9-1-10.
Client record #8 included a release of information form to a referral source that did not include the purpose of the disclosure. The purpose section on the form was blank. The client record included a release of information form to a family member that did not include the specific information to be disclosed or the purpose of the disclosure. The specific information section and the purpose section on the release of information form were both blank. The client record included a release of information form to a funding source that did not include the specific information to be disclosed or the purpose of the disclosure. The specific information section and the purpose section on the release of information form were both blank. All of the release of information forms were signed by client and the staff member on 9-15-10. The admission date for this client was 9-14-10.
Client record #9 included two separate release forms for two separate family members. Both release of information forms to the family members did not include the specific information to be disclosed or the purpose of the disclosure. The specific information sections and the purpose sections on the release of information forms were both blank. All of the release of information forms were signed by client and the staff member on 8-3-10. The admission date for this client was 8-3-10, and the discharge date is 8-23-10.
Client record # 10 included a release of information form to a family member that did not include the specific information to be disclosed or the purpose of the disclosure. The specific information section and the purpose section on the release of information form were both blank. The release of information form was signed by client and the staff member on 8-5-10. The admission date for this client was 8-5-10, and the discharge date is 8-31-10
|
Plan of Correction
Clinical Trainer, Kathryn Coleman will conduct a training on confidentiality and proper consent completion by December 31, 2010. Program Director will then monitor consents monthly for 6 months to ensure completion. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
|
Observations
Based on a review of client records, the narcotic treatment program failed to document the attempt to follow up with the client in three of six patient records.
The findings include:
Six client records were reviewed on October 18, 2010. Four client records are required to document an attempt to follow-up. The agency policy states that an attempt to follow-up with clients will occur within seven days of discharge.
Record #4 - Client was admitted on 7-8-10, and was discharged on 7-12-10. The follow up attempt was due within seven days of discharge on 7-19-10. There was no documentation of a follow up attempt.
Record #5 - Client was admitted on 8-23-10, and was discharged on 9-2-10. The follow up attempt was due within seven days of discharge on 9-9-10. There was no documentation of a follow up attempt.
Record #6 - Client was admitted on 4-14-10, and was discharged on 4-19-10. The follow up attempt was due within seven days of discharge on 4-26-10. There was no documentation of a follow up attempt.
|
Plan of Correction
Policy will be rewritten to state that follow up call will take place within 7 days when no aftercare was completed in extenuating circumstances. All clients that are referred to another level will be called within 5 business days of their follow up appointment. Follow up calls will be documented and monitored by the clinical supervisor and the program director monthly to ensure completion. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on client record review and a conversation with the staff, the facility failed to document a follow up attempt in one of two client records.
The findings include:
Ten client records were reviewed on October 18 -19, 2010. Four of the client records reviewed were representative of the inpatient non-hospital - residential treatment and rehabilitation activity. A follow up attempt was required in two of the client records. The facility did not document a follow up attempt in client record # 9. The facility policy states that follow up will be attempted within seven days of discharge.
Client record #9 - The admission date for this client was 8-3-10 and the discharge date is 8-23-10. A follow up attempt was due on 8-30-10. There was no documentation of an attempt to follow up on the client..
|
Plan of Correction
Policy will be rewritten to state that follow up call will take place within 7 days when no aftercare was completed in extenuating circumstances. All clients that are referred to another level will be called within 5 business days of their follow up appointment. Follow up calls will be documented and monitored by the clinical supervisor and the program director monthly to ensure completion. |