INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 8, 2025, 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 Chambersburg 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:
|
Plan of Correction
|
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor's caseload remained at or below 35 active clients.
Based on the total number of hours per week devoted to each client and the facility's standard work week of 40 hours as documented on the Staffing Requirements Facility Summary Report dated June 16, 2025, employee # 6 exceeded the allowable maximum 35/1 caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
Employee # 6 was hired as a counselor on December 16, 2024 and remains in that position at the time of the inspection. The FTE counselor ' s caseload calculation is as follows: 40 hours a week devoted to clients/40 hour work week=1(FTE); Employee #6 has 37 clients on their caseload which equals 37/1=37, which equals to a client/counselor ratio of 37/1.
This finding was reviewed by facility staff during the licensing process.
|
Plan of Correction
In response to the citation concerning 704.12, Licensure, outpatient caseload, FTE maximum client/staff and client/counselor ratios; all clinical staff caseload were reviewed by Executive Director and Clinical supervisor on 7/9/2025 to ensure all caseload assignments were in compliance of 35:1. In an effort to improve this deficiency in the future, Clinical Supervisor and Executive Director will review clinical staff caseloads on a weekly basis to ensure no staff members are over in caseload and all caseload assignments are correct within the electronic medical record.
- A review meeting was conducted by clinical supervisor with Counselor #6 to review current caseload and reassignment of two client overage. Caseload was reduced to appropriate ratio of 35:1 on 7/14/2025.
- To prevent any future caseload ratio deficiencies, Executive Director will compare caseload report in electronic medical record to case tracker for each clinical staff member on a weekly basis to ensure accuracy.
- Should a clinician be over in caseload at any point in time, immediate review reassignment of clients will occur by clinical supervisor.
Executive Director implemented plan of correction on 7/14/2025. Executive Director will continue to monitor caseload weekly by running caseload report in the electronic medical record and provide this list to Clinical supervisor to cross check with case tracker.
Executive Director implemented plan of correction on 7/14/2025. Executive Director will continue to monitor caseload weekly by running caseload report in the electronic medical record and provide this list to Clinical supervisor to cross check with case tracker. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included the dated signature of the client in one out of seven records reviewed.
Client # 2 was admitted on December 26, 2024 and was still active at the time of the inspection. The client record contained a release of information form to a funding source dated December 26, 2024, that did not include the dated signature of the client.
This finding wase reviewed with facility staff during the licensing process.
|
Plan of Correction
In response to the citation 709.28, Confidentiality, the project shall obtain an informed and voluntary consent from the client for disclosure of information contained in the client record; signature was noted as missing on consent form for client #2 from admission date of December 26, 2024, however was obtained later during treatment episode on February 27, 2025. During staff meeting on 7/9/2025 Executive Director and Clinical Supervisor reviewed the importance of obtaining vital signatures during the admission process on consent forms, as well as the implications of missing signatures. In an effort to comply with confidentiality regulations, the following will be implemented at the site:
- Executive Director will develop a checklist to be used during every client intake session to ensure consent forms are completed accurately, including signatures.
- Clinical Supervisor will review all intake documentation to ensure that all signatures are present when signing of consent bundles in the electronic medical record.
- Executive Director and Clinical supervisor will conduct monthly chart audits on any new intakes from the previous month on the first Monday of the new month (ex. June admits will be reviewed the first Monday of July), to ensure that all signatures are present on all consent forms.
Executive Director drafted intake check list on 7/14/2025 and distributed to staff during weekly staff meeting on 7/16/2025 and reviewed reasoning for the implementation of this checklist. Clinical supervisor began checking all admit consent bundles in electronic medical record that are routed to her for signature on 7/21/2025. All new admit charts for June 2025 were audited for the presence of consent signatures on 7/11/2025. All July admit charts will be audited on the first Monday in August 2025 and continue thereafter to ensure continued compliance. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in seven out of eight client records reviewed.
Client #1 was admitted on January 2, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated January 2, 2025, was offered to the client.
Client #2 was admitted on December 26, 2024 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated December 27, 2024, was offered to the client.
Client #3 was admitted on March 12, 2025 and was discharged on July 2, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated March 12, 2025, was offered to the client.
Client #4 was admitted on February 26, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated February 26, 2025, was offered to the client.
Client #5 was admitted on March 10, 2025 and discharged on May 29, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated March 10, 2025, was offered to the client.
Client #6 was admitted on October 29, 2024 and discharged on December 19, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated October 29, 2024, was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Pyramid Healthcare has submitted a ticket into its health records system to add an enhancement. This enhancement will denote that a copy of the Consent for Treatment, Payment and Healthcare Operations consent is offered to the client and will be memorialized and maintained in the client record. This denote will be a required field at the bottom of the document. As a result, staff will be unable to move forward to complete the document without the review and acknowledgement of whether a copy was offered to the client or not. Compliance monitors on a monthly basis the completion of the Consent for Treatment, Payment and Healthcare Operations consent for all clients active in treatment. The monitoring information is shared with the facilities operations and clinical leadership team through a scorecard to review and identify if any client receiving care may be missing one. If clients are determined to be missing a document, facility leadership and/or designee will be responsible for ensuring completion of the Consent for Treatment, Payment and Healthcare Operations consent with those clients and offering a copy.
Executive Director and Clinical Supervisor will re-educate staff on the expectation to offer a copy of the Treatment, Payment and Healthcare Operations consent to each client and document that offering on the updated consent form in weekly team meeting by 8/31/2025. This re-education will be recorded in the meeting minutes/notes.
In order to monitor compliance with our plan of correction, the Clinical Supervisor will be responsible for weekly supervision with direct care staff to ensure compliance. Executive Director will supervise the Clinical Supervisor weekly to monitor the plan of correction. Executive Director will provide updates to the Regional Director bi-weekly to ensure compliance with plan of correction.
|