INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 3, 2024 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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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 14 days or five sessions following admission.
Client #2 was admitted on October 5, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than October 19 2023; however, it was not completed until November 28, 2023.
Client #3 was admitted on January 25, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 8, 2024; however, it was not completed until May 5, 2024.
Client #4 was admitted on November 20, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 5, 2023; however, it was not completed until January 8, 2024.
Client #5 was admitted on October 30, 2023 and discharged on January 4, 2024. A comprehensive treatment plan was due no later than November 13, 2023; however, it was not completed until January 4, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In response to the citation concerning 709.92(a), Treatment and rehabilitation service, an individual treatment and rehabilitation plan shall be developed with a client. To reflect our facility's policy and procedures manual, the comprehensive treatment plan will be completed within 14 days or five sessions following admission. This initial treatment planning session will be scheduled within the first week of admission into the program. All clinical staff were re-educated on July 8, 2024 about treatment plan requirements during weekly staff meeting by Executive Director. In an effort to improve this deficiency in the future, Executive Director will be updating the case tracker with the following information:
The next individual appointment column will be dated 7 days from initial assessment date. This will ensure a comprehensive treatment plan is updated within the 14 day period per the facility's policy. This will also provide the clinical staff a short window of time to reschedule the client, should they cancel and/or no show their scheduled treatment plan session, without treatment plan becoming delinquent. Clients will also be notified of the importance in maintaining their initial appointment following admission into the program.
Changes to the case management log were made by Executive Director on 7/5/2024 and plan of correction has been implemented. Executive Director will ensure case management log is updated weekly and clinical staff were educated to review the case management log at the beginning of each shift to ensure treatment plans are completed timely and individual sessions have been scheduled for all clients on their caseload. Furthermore, in another effort to assist the clinicians, the Executive Director has begun putting notes on the clinicians' scheduled appointments indicating if treatment plan is needed.
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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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of six records reviewed.
Client #1 was admitted on January 31, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 15, 2024 and an update was due no later than April 16, 2024; however, it was not completed until April 25, 2024.
Client #2 was admitted on October 5, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on November 28, 2023 and an update was due no later than January 28, 2024; however, it was not completed until January 31, 2024. Additionally, the next update was due no later than March 31, 2024; however, it was not completed until April 3, 2024.
Client #4 was admitted on November 20, 2024 and was still active at the time of the inspection. A treatment plan update was completed on January 8, 2024 and the next update was due no later than March 9, 2024; however, it was not completed until April 25, 2024.
Client #6 was admitted on September 7, 2023 and was discharged on January 19, 2024. A treatment comprehensive plan was completed on September 14, 2023 and an update was due no later than November 14, 2023; however, it was not completed until December 7, 2023.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 6, 2023 licensing inspection.
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Plan of Correction
In response to the citation concerning 709.92(b), Treatment and rehabilitation service, treatment and rehabilitation plans shall be reviewed and updated every 60 days; all clinical staff were re-educated on July 8, 2024 about treatment plan requirements during weekly staff meeting by Executive Director. In an effort to improve this deficiency in the future, Executive Director will be updating the case management log with the following information:
Treatment plan update column will be dated 30 days from last treatment plan update. This will ensure treatment plans are updated within the 60 day review period. This will also provide the clinical staff a short window of time to reschedule the client, should they cancel and/or no show their scheduled treatment plan session, without treatment plan becoming delinquent.
The next individual appointment column utilized on the case management log indicating when their next individual session is scheduled for to ensure clients are scheduled for their individual session within the 60 day review period for the treatment plan.
Executive Director will place note on client's individual appointment on the clinician's schedule, indicating that treatment plan update is due, as a second reminder for the clinician should they not review the case management log prior to appointment.
Changes to the case management log were made by Executive Director on 7/5/2024 and plan of correction has been implemented. Executive Director will ensure case management log is updated weekly and clinical staff were educated to review the case management log at the beginning of each shift to ensure treatment plans are completed timely and individual sessions have been scheduled for all clients on their caseload. Furthermore, in another effort to assist the clinicians, the Executive Director has begun putting notes on the clinicians' scheduled appointments indicating if treatment plan is needed.
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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 client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in two out of six applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed within 90 days following admission.
Client #3 was admitted on January 25, 2024 and was still active at the time of the inspection. A case consultation was due no later than April 26, 2024; however, it was not completed until June 27, 2024
Client #4 was admitted on admitted on November 20, 2023 and still active at the time of the inspection. A case consultation was due no later than February 20, 2024; however, it was not completed until June 20, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In response to citation concerning 709.93(a), Client Records, Executive Director reviewed regulations/time frames for completion of case consultations during treatment team meeting on July 8, 2024. Executive Director will utilize the case management log to record the due date for all case consultations during the first year in treatment. This will include the patient's start date and the quarterly due date.
Executive Director will email counselors monthly with case consultation that are coming due. Counselors will review case consultations during weekly treatment team meetings. Executive Director will review patient chart to ensure the case consultation review was completed.
Changes to the case management log were made by Executive Director on 7/5/2024 and plan of correction has been implemented. Executive Director will ensure case management log is updated weekly and clinical staff were educated to review the case management log at the beginning of each shift to ensure case consultations are completed within a 75 day period. This provide the clinical staff a short window of time to solidify the completion of the case consultation within the 90 day regulation window. Furthermore, in another effort to assist the clinicians, the Executive Director has begun putting notes on the clinicians' scheduled appointments indicating if a case consultation is needed.
In addition, the Quality Team reviews quality and compliance indicators on a monthly basis and reviews during monthly key performance indicator meetings with site leadership. A random sample of charts is monitored each month. The Quality team monitors the following indicator each month with a benchmark goal of 80%. Site leadership will work with the quality team to address any indicator below the benchmark score and will provide additional training and resources as needed.
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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 client records, the facility failed to document a discharge summary within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states the that discharge summary must be completed seven days following discharge.
Client #7 was admitted on June 26, 2023 and was discharged on February 5, 2024. A discharge summary was due no later than February 12, 2024; however, it was not completed until February 19, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In response to citation concerning 709.93(a), Client Records, the facility's policy and procedures manual states that the discharge summary must be completed seven days following discharge; all clinical staff were educated on July 8, 2024 about discharge summary completion. Staff were informed the discharge summary must be completed within 5 days of completion of the discharge management plan.
Clinical staff will route discharge management plan and treatment summary to Executive Director for review. Once all documentation is completed, Executive Director will review chart, complete signature of documentation, and close client record in electronic medical record.
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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 client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states the that the follow up must be completed within seven days following discharge.
Client #6 was admitted on September 7, 2023 and discharged on January 19, 2024. A follow up was due no later than January 26, 2024; however, it was not completed until February 1, 2024.
Client #7 was admitted on June 26, 2023 and was discharged on February 5, 2024. A follow up was due no later than February 12, 2024; however, it was not completed until February 21, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June6, 2023 licensing inspection.
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Plan of Correction
In response to citation concerning 709.93(a), Client Records, the facility's policy and procedures manual states that the follow up must be completed within seven days following discharge; all clinical staff were educated on July 8, 2024 about follow up discharge call completion. Staff were informed the call must be completed within 5 days of completion of the discharge management plan.
Clinical staff will route discharge management plan and treatment summary to Executive Director for review. Upon review of these documents, Executive Director will review if discharge follow up call documentation was completed. If not completed, Executive Director will not sign off on documentation until call is completed. Executive Director will notify clinical staff of incomplete documentation and inform clinical staff to notify Executive Director when complete.
Once all documentation is completed, Executive Director will review chart, complete signature of documentation, and close client record in electronic medical record.
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