INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 31- August 1, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Pyramid Healthcare Inc., Erie Outpatitent 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
The facility failed to document a six-month performance evaluation for staff #10.
Staff #10 was hired on March 27, 2018 as a counselor assistant and was still in the position as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff member in question was moved to a Counselor Assistant prior to inspection. Weekly supervision has been and will continue to be conducted by Clinical Supervisor. Executive Director will be responsible for the monitoring that this regular supervision is occurring.
Upon application counselors with limited experience or questionable degrees will be reviewed by Chief Compliance Office and Human Resources, to determine level of supervision requirements. |
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
The facility failed to document close supervision for at least the first six months of employment as a counselor assistant for staff #10.
Staff #10 was hired on March 27, 2018, with a Bachelor's Degree, and was still employed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff member in question was moved to a Counselor Assistant prior to inspection. Weekly supervision has been and will continue to be conducted by Clinical Supervisor. Executive Director will be responsible for the monitoring that this regular supervision is occurring.
Upon application counselors with limited experience or questionable degrees will be reviewed by Chief Compliance Office and Human Resources, to determine level of supervision requirements. |
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.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 3.
Client #3 was admitted on May 3, 2018 and was still in active client at the time of the inspection. A consent to release form was signed and dated on September 18, 2017 to the funding source and to a government agency that allowed for the release of the psychiatric evaluation, treatment progress update, history and physical, psychosocial assessment, prognosis, and medication administration.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Releases Training will be concluded by September 2018 and will be conducted by Clinical Supervisor and Executive Director. Completion of training will be verified by post-test completion and monitored by supervisors through random chart monitors. Compliance of consents will continue to monitored by Vice President of Corporate Compliance and the team of Clinical Coordinators. Clinical Coordinators and Clinical Supervisors will continue to monitor releases weekly when chart monitors are completed. Extra individual supervision around proper completion of releases relating to 255.5 will be completion specifically with the staff member in question. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to provide documentation that the clients received counseling services according to their individual comprehensive treatment plan in client record # 1, 7, and 8.
Client # 1 was admitted on March 15, 2018 and was still active at the time of the inspection. The comprehensive treatment plan, dated March 30, 2018 , indicated 5 group sessions per week (or 20 groups per month) and 2 individual sessions per week. The chart's record of service and progress notes indicates either no individual sessions or only 1 individual session the weeks April 22 to April 28, 2018, April 29 to May 5, May 6 to May 23, May 25 to June 8, 2018, June 10 to June 15, 2018.
Client # 7 was admitted on march 3, 2018 and was still active at the time of the inspection. The comprehensive treatment plan, dated April 13, 2018, indicated weekly group sessions per week (or 4 groups per month). The chart's record of service and progress notes indicated that the client had received 3 group sessions in March and 1 group session in July.
Client # 8 was admitted on May 22, 2018 admitted on 03/22/2017 and was still active at the time of the inspection. The comprehensive treatment plan, dated May 22, 2018, indicated 3 group sessions per week (or 12 groups per month) and 1 individual bi-weekly. The chart's record of service and progress notes indicated that the client had received 2 group sessions i May, 9 group sessions in June, and 7 group sessions in July. 1 individual sessions was recorded for June 6, 2018 and there were no other individual sessions documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will ensure services are offered and completed as prescribed in the client's treatment plans. Completion of individual sessions twice weekly in the Acute Partial and Partial levels of care will be monitored through a monthly open chart monitor. Clinical Supervisor will complete chart monitors and review in monthly supervision. Executive Director will be responsible for ensuring follow up that this is being completed. Clinical Coordinators will also be completing monthly chart monitors randomly on 10% of the counselor's caseloads. The individual counselors in question, will have more supervision targeted around these areas. Clinical training was conducted September 2018 about proper documentation of treatment planning. |