INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 30, 2021 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of ten personnel records, it was determined that that one employee did not meet the educational requirements to be a counselor.
Employee #7 was hired as a counselor on July 5, 2021 and was still current in that position. At the time of the hire, the employee had a bachelor ' s degree in psychology, and no clinical experience.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Since the inspection the identified personnel has resigned from the position of Counselor and is no longer with Pyramid Healthcare Inc.
To ensure we are meeting the required qualifications for personnel hired the Executive Director will send all resumes and applications to the Corporate Compliance team for review.
The Corporate Compliance team will review the applications and resumes and compare them to the requirements of the state for hire and to ensure they meet the required qualifications.
Once approved by the Corporate Compliance team the applicant will be hired either as a counselor our counselor assistant with the appropriate degree.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and ten personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the facility director in one employee record reviewed.
Employee #2 was hired as a facility director on September 23, 2013 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2020 through December 31, 2020. Employee #2's employee record only documented 8.75 hours of annual training for the training year reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Executive Director has developed a training tracking grid for all staff members that will allow him to track training hours to ensure staff are meeting their requirements.
This grid is updated and checked at the beginning of each month to ensure counselors and all staff are on tack to meet hours.
Executive Director will be using Pyramid wide training system, Relias, to ensure all counselors are uploading certificates of completion for external trainings as well as assign any staff who are low on training hours for the month the trainings they need to meet this requirement.
Trainings can be assigned at any time within the system.
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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 six partial client records, the facility failed to ensure that all clients received an individualized comprehensive treatment plan in five of the client records reviewed.
Client #9 was admitted on June 28, 2021 and was still active at the time of the inspection.
Client #10 was admitted on July 19, 2021 and was still active at the time of the inspection.
Client #11 was admitted on August 6, 2021 and was still active at the time of the inspection.
Client #12 was admitted on May 25, 2021 and was discharged on June 29, 2021.
Client #13 was admitted on April 20, 2021 and was discharged on June 8, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Executive Director will be restructuring PHP programming for this office. PHP will run with 2 counselors as of 10/11/2021. Counselor 1 will run group M/ W/F and Counselor 2 will see clients for individual sessions. Counselor 2 will run group on T/TH while Counselor 1 is meeting with clients for the additional individual sessions 2x per week.
Both counselors will be responsible for completing a PHP caseload tracker weekly, which will identify when the treatment plan for each client is completed and the date it will need to be updated. It will be required of the counselors to complete the treatment plans at weekly sessions.
Executive Director and Clinical Supervisor will have daily access to the PHP tracker and will be completing an audit internally on a weekly basis to ensure that the tracker is completed and that treatment plans are in each individual chart.
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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 six partial client records, the facility failed to ensure that clients received a treatment plan update every 30 days in one applicable client record reviewed.
Client #8 was admitted on July 6, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was completed on Jul 23, 2021 and an update was due no later than August 23, 2021; however, there was no update documented in the record at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Executive Director will be restructing PHP programming for this office. PHP will run with 2 counselors as of 10/11/2021. Counselor 1 will run group M/ W/F and Counselor 2 will see clients for individual sessions. Counselor 2 will run group on T/TH while Counselor 1 is meeting with clients for the additional individual sessions 2x per week.
Both counselors will be responsible for completing a PHP caseload tracker weekly which will identify when the treatment plan for each client is completed and the date it will need to be updated which will be every 30 days. It will be required of the counselors to complete the treatment plans at weekly sessions or schedule client at the 30 day required mark.
Executive Director and Clinical Supervisor will have daily access to the PHP tracker and will be completing an audit internally on a weekly basis to ensure that the tracker is completed and that treatment plans are in each individual chart and updated every 30 days.
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709.82(c) LICENSURE Treatment and rehabilitation services
709.82. 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
Based on a review of six partial client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in all six client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Executive Director will be restructing PHP programming for this office. PHP will run with 2 counselors as of 10/11/2021. Counselor 1 will run group M/ W/F and Counselor 2 will see clients for individual sessions. Counselor 2 will run group on T/TH while Counselor 1 is meeting with clients for the additional individual sessions 2x per week.
Both counselors will be responsible for completing a PHP caseload tracker weekly which will identify when the client needs to be seen for individual sessions and group sessions. Counselor will ensure that clients are coming for these required sessions, and if not reach out attempts will be made. It will be required of the counselors to ensure attendance of each client based on their comprehensive treatment plan.
Executive Director and Clinical Supervisor will have daily access to the PHP tracker and will be completing an audit internally on a weekly basis to ensure that the tracker is completed and clients are schedule and attending their required 2x weekly individual sessions. |
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 six partial client records, the facility failed to ensure that all clients received at least two individual session a week in all six client records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Executive Director will be restructuring PHP programming for this office. PHP will run with 2 counselors as of 10/11/2021. Counselor 1 will run group M/ W/F and Counselor 2 will see clients for individual sessions. Counselor 2 will run group on T/TH while Counselor 1 is meeting with clients for the additional individual sessions 2x per week.
Both counselors will be responsible for completing a PHP caseload tracker weekly which will identify when the client needs to be seen for individual sessions and group sessions. Counselor will ensure that clients are coming for these required sessions, and if not reach out attempts will be made. It will be required of the counselors to ensure attendance of each client based on their comprehensive treatment plan.
Executive Director and Clinical Supervisor will have daily access to the PHP tracker and will be completing an audit internally on a weekly basis to ensure that the tracker is completed and clients are schedule and attending their required 2x weekly individual sessions.
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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 six partial client records, the facility failed to ensure that all discharged records include a discharge summary in one of the two applicable records.
Client #13 was admitted on April 20, 2021 and was discharged on June 8, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Executive Director will be restructuring PHP programming for this office. PHP will run with 2 counselors as of 10/11/2021. Counselor 1 will run group M/ W/F and Counselor 2 will see clients for individual sessions. Counselor 2 will run group on T/TH while Counselor 1 is meeting with clients for the additional individual sessions 2x per week.
The PHP tracker will not only monitor client engagement with appointments but will also monitor discharge / step down paperwork requirements for each client in PHP programming. These discharge / transition bundles will be documented on the tracker and expected to be completed by the Counselors. The PHP tracker is reviewed weekly and reviewed each Monday with all staff during staff meeting.
The tracker will be monitored weekly by the Executive Director and Clinical Supervisor for completion of discharge paperwork as well as the required 7 day reach out call after discharge.
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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 six partial client records, the facility failed to ensure that two of the two applicable client records contained documentation of follow up information.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Executive Director will be restructuring PHP programming for this office. PHP will run with 2 counselors as of 10/11/2021. Counselor 1 will run group M/ W/F and Counselor 2 will see clients for individual sessions. Counselor 2 will run group on T/TH while Counselor 1 is meeting with clients for the additional individual sessions 2x per week. Using the PHP tracker to ensure meeting of appointments and tracking the PHP caseloads.
Added into the tracker is a daily check to ensure proper outreach / re-engagement calls are being made by the counselors as well as a completion of call logs in the clients active chart. This will be required of the counselor to update on the tracker daily and outreach attempts will be monitored weekly.
The tracker will be monitored weekly by the Executive Director and Clinical Supervisor for completion of outreach / follow up calls and proper call log documentation.
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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 seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in all seven client records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
For all clinical staff, Executive Director and Clinical Supervisor created a Case tracker for staff to utilize. This tracker was trained and implemented on 9/13/2021 with all counselors holding a caseload. Each tracker monitors attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion pending discharge dates and when next appointments are scheduled. Counselors are required to update tracker daily as meeting with clients.
Executive Director and Clinical Supervisor monitor this tracker three times per week and review them with all staff weekly. Additionally, ED and CS review the tracker weekly in a meeting with the Regional Director.
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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
Based on a review of seven outpatient client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in all seven client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
For all clinical staff, Executive Director and Clinical Supervisor created a Case tracker for staff to utilize. This tracker was trained and implemented on 9/13/2021 with all counselors holding a caseload. Each tracker monitors attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion pending discharge dates and when next appointments are scheduled. Counselors are required to update tracker daily as meeting with clients. This is a section on the tracker which identifies the last time a client was seen for an individual session and when the next appointment is scheduled.
Counselors are also required to provide group attendance sheets daily to Clinical Supervisor and Executive Director and identify clients that are not engaging. Follow up calls are to be completed and documented in a Call log. These are monitored by the CS and reviewed weekly at staff meeting.
Executive Director and Clinical Supervisor monitor this tracker three times per week and review them with all staff weekly. Additionally, ED and CS review the tracker weekly in a meeting with the Regional Director.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of seven client outpatient client records, there was no documentation that the clients received case consultations within the first 90 days and yearly afterwards in all seven client records.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
For all clinical staff, Executive Director and Clinical Supervisor created a Case tracker for staff to utilize. This tracker was trained and implemented on 9/13/2021 with all counselors holding a caseload. Each tracker monitors attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion pending discharge dates and when next appointments are scheduled. Counselors are required to update tracker daily as meeting with clients.
Each staff member has been trained on how to use the case tracker. This is a section on the tracker which identifies case consult due dates. Staff are also required to provide a case consult at each change in Level of Care. This is reviewed weekly in staff meeting when each staff member discusses clients that are changing level of care. CS monitors these cases weekly to ensure all transition paperwork is completed.
ED and CS monitor this tracker three times per week and review them with all staff weekly. Additionally, ED and CS review the tracker weekly in a meeting with the Regional Director.
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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 seven outpatient client records the facility failed to document an aftercare plan in two of the three applicable client records reviewed.
Client #5 was admitted on June 16, 2020 and was discharged on May 25, 2021.
Client #6 was admitted on August 28, 2021 and discharged on May 19, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
For all clinical staff, Executive Director and Clinical Supervisor created a Case tracker for staff to utilize. This tracker was trained and implemented on 9/13/2021 with all counselors holding a caseload. Each tracker monitors attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion pending discharge dates and when next appointments are scheduled. Counselors are required to update tracker daily as meeting with clients.
There is a section on the tracker which identifies Aftercare plan due dates. Staff are required to provide an Aftercare plan for every successful and unsuccessful discharge. Executive Director and Clinical Supervisor will review trackers and expected discharge dates then ensure paperwork is completed by weekly audit.
CS will ensure that outreach calls are made for a client after they miss a scheduled session and that staff adhere to our discharge process.
ED and CS monitor this tracker three times per week and review them with all staff weekly. Additionally, ED and CS review the tracker weekly in a meeting with the Regional Director.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of seven outpatient client records the facility failed to document a discharge summary in two of the three applicable client records reviewed.
Client #5 was admitted on June 16, 2020 and was discharged on May 25, 2021.
Client #6 was admitted on August 28, 2021 and discharged on May 19, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
For all clinical staff, Executive Director and Clinical Supervisor created a Case tracker for staff to utilize. This tracker was trained and implemented on 9/13/2021 with all counselors holding a caseload. Each tracker monitors attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion pending discharge dates and when next appointments are scheduled. Counselors are required to update tracker daily as meeting with clients.
There is a section on the tracker which identifies Discharge Summary due dates. Staff are required to provide a Discharge Summaries for every successful and unsuccessful discharge. Executive Director and Clinical Supervisor will review trackers and expected discharge dates then ensure paperwork is completed by weekly audit.
CS will ensure that outreach calls are made for a client after they miss a scheduled session and that staff adhere to our discharge process.
ED and CS monitor this tracker three times per week and review them with all staff weekly. Additionally, ED and CS review the tracker weekly in a meeting with the Regional Director.
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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 seven outpatient records, the facility failed to ensure that all three applicable client records contained documentation of follow up information.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
For all clinical staff, Executive Director and Clinical Supervisor created a Case tracker for staff to utilize. This tracker was trained and implemented on 9/13/2021 with all counselors holding a caseload. Each tracker monitors attendance, treatment plan due dates, case consult due dates, psychosocial evaluation completion pending discharge dates and when next appointments are scheduled. Counselors are required to update tracker daily as meeting with clients.
There is a section on the tracker which identifies when 7 Day follow up calls for all discharged clients. Staff are required to provide a 7 Day follow up call for every successful and unsuccessful discharge. Executive Director and Clinical Supervisor will review trackers and expected discharge dates then ensure 7 day follow up calls are completed by weekly audit.
Clinical Supervisor will ensure that outreach calls are made for a client after they miss a scheduled session and that staff adhere to our discharge process.
ED and CS monitor this tracker three times per week and review them with all staff weekly. Additionally, ED and CS review the tracker weekly in a meeting with the Regional Director. |