INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2007 to March 13, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on April 13, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback was not consistently documented in a manner that allowed for inspectors to be able to determine compliance with facility policy.
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Plan of Correction
Human Resource Coordinator will train staff to complete training evaluations after all trainings and she will place the evaluations in the employees' personnel files. This is currently in compliance. This will be monitored by Human Resource Coordinator on an annual basis through personnel file monitoring. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The manual at the main administrative office and the manuals at the various locations reviewed were not consistent with regard to policies and procedures. The general organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures.
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Plan of Correction
All policies and procedures are submitted to the policy review committee by JCAHO Staff Coordinator for approval and distribution. All new or revised policies are distributed to all program directors and reviewed at the monthly Performance Improvement Committee meetings. The program director is responsible for training all staff on the new or revised policy. The Performance Improvement Committee will be responsible for the oversight of the implementation of all policies. The Performance Improvement will immediately begin auditing program policy and procedure manuals to ensure consistency between all manuals. Compliance is current. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
The HIPAA Notice of Privacy Practices form has errors in sections III L.and O.; IV. F; V. A and C.; VI E and H and VII., exceeding what is allowed in federal and state laws. Confidentiality of clients' individual treatment plans must be preserved by formulating those plans with the clients in an individual treatment session. Failure to do so breaches a clients confidentiality and could/would inhibit the clients' willingness to address personal/private issues.
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Plan of Correction
The HIPAA Notice of Privacy Practices Policy was revised on April 2nd, 2007 by Director of Medical Records. All observations noted in section 0277 of the Erie deficiency listing have been corrected. The revised policy has been approved by the policy review committee and will be distributed to all programs immediately. The revised policy will be reviewed at the monthly Performance Improvement Committee meeting. The Program Director will be responsible for training all staff on the revised policy. The Performance Improvement Committee will be responsible for the oversight of the implementation of the new policy. The revised HIPAA Notice of Privacy Practices Policy is available for review upon request. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Administrative policy stipulates that a physical examination should be conducted on all clients. No physical examinations were completed.
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Plan of Correction
Section IV of the Pyramid Healthcare History and Physical Policy states that:
A History and Physical is not required for admission to the outpatient program.
- A risk assessment is performed upon initial intake.
- If the risk assessment indicates a need, the client is referred to their PCP or another physician for a complete history and physical examination.
In response to the deficiency listing the above items were removed from the History and Physical policy and a History and Physical-Outpatient Policy was created on March 5th, 2007. The policy was distributed to all programs by the JCAHO Staff Coordinator on March 7th, 2007. The Program Director will be responsible for training all staff on the revised policy. The Performance Improvement Committee will be responsible for the oversight of the implementation of the new policy. Both policies are available for review upon request.
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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
All clients records contained individualized treatment plans. Client records # 2 and 6 contained treatment plan updates but there were no individual sessions documented after the initial session. The Department of Health's interpretation of individualized treatment is not met by treatment plans or treatment plan updates appearing to be completed in group sessions. All treatment plans and updates should be completed in an individual session.
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Plan of Correction
Treatment plans and treatment plan updates are not completed in group sessions.
Program Director has instructed staff to provide individualized treatment and document this on treatment plans and in both individual and group notes.
Program Director will monitor monthly in chart review process. Compliance is current. |