INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 2, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to supervise a counselor assistant by a full-time clinical supervisor or counselor who meets the qualifications. In addition, the project must have a full time clinical supervisor on staff for every 8 full time counselors and based on the SRFSR, the facility does not employ a full time clinical supervisor.Employee #9 was hired on April 8, 2022 as a Counselor Assistant and was still employed at the time of the inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Pyramid Allentown promoted a clinical supervisor on July 30, 2023. Staffing structure will continue to provide 1 clinical supervisor for every 8 counselors moving forward. In the event that a clinical supervisor leaves the position, the Executive Director will take over the responsibilities of the clinical supervisor and the Regional Director will assume the responsibilities of the Executive Director until a suitable and qualified candidate is on boarded to support the appropriate staffing structure of one clinical supervisor for every 8 therapists. |
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 four of seven applicable outpatient client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records #8, #9, #12, and #13Client # 8 was admitted on February 9, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on March 17, 2023. A treatment and rehabilitation plan update was due no later than May 17, 2023. A treatment and rehabilitation plan update did not occur until June 1, 2023.Client # 9 was admitted on January 17, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 23, 2023. A treatment and rehabilitation plan update was due no later than March 23, 2023. A treatment and rehabilitation plan update did not occur until May 8, 2023.Client # 12 was admitted on August 17, 2022 and was discharged on February 27, 2023. A treatment and rehabilitation plan was developed on September 5, 2022. A treatment and rehabilitation plan update was due no later than November 5, 2022. A treatment and rehabilitation plan update did not occur until January 18, 2023.Client # 13 was admitted on February 6, 2023 and was discharged on June 28 ,2023 . A treatment and rehabilitation plan was developed on February 8, 2023. A treatment and rehabilitation plan update was due no later than April 8, 2023. There was no documentation of a treatment plan update in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RQM will continue to monitor charts for required documentation monthly. Clinical Supervisor will review treatment plan compliance for each caseload prior to monthly individual and group supervision. Clinical Supervisor and clinical staff will address treatment plan deficiencies; schedule the client for the next available individual session or prior to the next scheduled group service. Clinical Supervisor and clinical staff will review upcoming treatment plans for the next month, utilize alerts on the face sheet to set a reminder for the upcoming treatment plan, and will schedule the first individual session for each month as a treatment plan session. Our Quality Specialist Team will continue to complete monthly chart monitors and will look to ensure treatment plans are completed timely. After monthly audits, the facility leadership will meet to review the results and follow up with any identified deficiencies. |
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 three of three applicable outpatient client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 7 days after discharge.Client #12 was admitted on August 17, 2022 and was discharged on February 27, 2023.There was no follow-up information available in the client record.Client #13 was admitted on February 6, 2023 and was discharged on June 28, 2023. There was no follow-up information available in the client record. Client 14 was admitted on April 20, 2023 and was discharged on July 20, 2023. There was no follow up information available in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will pull the discharge report from the previous week each Monday. This list will be given to the CRS staff to perform outreach calls as they are the best equipped to discuss and encourage continued engagement in treatment and to offer community support. ED will review the list at the end of the week and ensure all outreach calls are completed and logged. Our Quality Specialist Team will continue to complete monthly chart monitors and will look to ensure outreach calls are completed timely. After monthly audits, the facility leadership will meet to review the results and follow up with any identified deficiencies. |