INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23-35, 2015, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. 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 personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of six personnel records reviewed.
The findings include:
Six clinical personnel records were reviewed on June 24, 2015. The facility failed to ensure that employee # 6 met the educational requirements for the position of counselor.
Employee #6 was hired as a bachelor's level counselor on March 23, 2015. Employee #6 did not meet the qualifications for the position of counselor as they did not have a bachelor's degree with an approved major. Employee #6 received a BA in Journalism and does not have prior clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 6/26/2015, the staff person identified is a case manager and not working in a counseling role. The hiring supervisor will ensure that counseling staff meet the couselor requirements according to DDAP standards. The Program Manager and regional HR Director will review the credentials of all potential employees to ensure the individuals meet the qulaifications for the desired position prior to hiring. The DDAP staffing requirements will be reviewed with all hiring managers on the Leadership Meeting on 8/6/15. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facilities staff scheduled work hours and the First Aid and CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR and First Aid during the project's hours of operation.
The findings include:
The CPR certification cards and First Aid certification cards were reviewed on June 24-25, 2015. The facility failed to have sufficient 24 hour/7 day CPR coverage.
Main House - Lack of sufficient CPR coverage 8:00am to 4:00pm Monday through Friday and Tuesday's from 4:00 pm to 12:00am.
Lake House - Lack of sufficient CPR coverage 12:00am to 8:00am Monday through Thursday, 8:00 am to 4:00 pm Monday through Friday, and 12:00pm to 8:00pm Thuesday, Thursday, Saturday and Sunday.
Farm House - Lack of sufficient CPR coverage 12:00am to 8:00am Friday through Sunday, 8:00am to 4:00pm Saturday and Sunday, 4:00pm to 12:00am Monday through Sunday.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 7/30/15, the Clinical Secretary and Residential Coordinator will ensure that there is a sufficient number of staff persons trained in CPR and First Aid during the hours of operation which is 24 hous per day, 7 days per week. A CPR and First Aid training was held on 7/30/2015 at the facility to provide training for staff who were not previously trained or who's certification has expired or is due to expire. The Clinical Secretary will schedule CPR and First Aid trainings at quarterly intervals to ensure a sufficient number of staff are trained. The clinical secretary will also review the list of trained staff quarterly to indentify staff whose certification is due to expire and schedule the identified staff for training prior to expiration. Additionally, the Residential Coordinator will ensure that there is a sufficient number of trained staff on each shift when creating the staffing schedule each month. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of non-hospital detoxification client records, the facility failed to document a psychosocial evaluation in four of four client records reviewed.
The findings include:
Four client records requiring documentation of a psychosocial evaluation were reviewed on June 23, 2015. The facility failed to document a psychosocial evaluation in client records #1, 2, 3 and 10.
Client #1 was admitted on 4-8-2015 and discharged on 4-13-2015. A psychosocial evaluation was not documented in the client's record.
Client #2 was admitted on 4-30-2015 and discharged on 5-5-2015. A psychosocial evaluation was not documented in the client's record.
Client #3 was admitted on 3-21-2015 and discharged on 3-26-2015. A psychosocial evaluation was not documented in the client's record.
Client #10 was admitted on 6-15-2015 and is an active client. A psychosocial evaluation was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 7/30/2015, the Clinical Director will ensure that psychosocial evaluations are completed for all non-hospital detoxification clients within 3 days of admission to the program. On 6/24/2015 the clinical director notfied the eCR Clinical Coordinator that this document was not available in the detox chart of the electronic clinical record. On 6/26/2015 the eCR Clinical Coordinator added this document to the detox chart structure. On 6/26/2015 the clinical director notified the detox counselor that the psychosocial evaluation must be completed on all detox clients within 3 days of admission. The clinical director will monitor compliance via monthly chart audits. |
709.63(a) LICENSURE Client record
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:
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Observations
Based on a review of the non-hospital detoxificationclient records, the facility failed to document a complete client record in four of four client records.
The findings include:
Four client records were reviewed on June 23, 2015. The facility failed to document record of service, progress notes, discharge summary or follow up information in client records, #1, 2, 3 and 10.
Client #1 was admitted on 4-8-2015 and discharged 4-13-2015. The facility failed to document a record of service, progress notes and a discharge summary in client #1's record.
Client #2 was admitted on 4-30-2015 and discharged 5-5-2015. The facility failed to document a record of service, progress notes and a follow-up in client #2's record.
Client #3 was admitted on 3-21-2015 and discharged 3-26-2015. The facility failed to document a record of service, progress notes and a follow-up in client #3's record.
Client #10 was admitted on 6-15-2015 and is an active client. The facility failed to document a record of service and progress notes in client #10's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 7/31/2015, the Clinical Director will ensure that all client records are complete. On 6/26/2015 the clinical director met with the detox counselor to review the documentation required in all detox charts as well as the time frames for completion. The following documentation was discussed: record of service, progress notes, discharge summary and follow up information. Documentation idenfied as missing will be completed by 8/10/2015 by the detox counselor. The Nurse manager will monitor compliance via monthly chart audits. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on the review of client records, the facility failed to provide a complete client record on each individual in two of six client records.
The findings include:
Ten client records were reviewed on June 23-24, 2015. Six client records were reviewed for the inpatient non-hospital - residential treatment activity, and complete client records were required. The facility did not provide a complete client record for records #4 and #5.
Client #4 was admitted to treatment on December 14, 2014 and was discharged on February 19, 2015. Record #4 did not have documentation of Consent to Release Information for Funding .
Client #5 was admitted to treatment on January 22, 2015 and was discharged on February 22, 2015. Record #5 did not have documentation of a Preliminary treatment and Rehabilitation plan or an Aftercare Plan.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 7/31/2015, the Clinical Director will ensure that all client records are complete. On 7/10/2015 the clinical director held a clinical staff meeting to review the documentation required in all inpatient rehab charts as well as the time frames for completion. The following documentation was discussed: consents to release information, preliminary treatment plan and aftercare plans. Documentation idenfied as missing will be completed as appropriate by 8/10/2015 by the client's primary counselor. The clinical director will monitor compliance via monthly chart audits. |