INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15-16, 2018, by staff from the Division of Drug and Alcohol 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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704.12(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.
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Observations
The facility facility exceeded the maximum caseload for a clinician in 1 of 9 staff records reviewed. The full-time equivalent counselor caseload in outpatient treatment is determined by dividing the number of active patients assigned to the individual counselor, counselor assistant or clinical supervisor by the full-time equivalent (FTE). The FTE is determined by dividing the number of hours the individual counselor, counselor assistant or clinical supervisor devotes to patients each week by 35. Staff Person #2 is a full time clinical supervisor with an active caseload of 12 patients. The staff person devotes 3 hours a week to patients. Staff Person #2 (3/35 = 0.0857 FTE) 12 patients/ 0.0857 = 140:1 caseload. The maximum FTE caseload for outpatient treatment is 35:1, but Staff Person #2 has a caseload of 140:1. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
As of 9-30-18, we have increased the hours of direct service for the Clinical Supervisor to 10 hours / week and have reduced her caseload to 10 clients. Ongoing, the Program Director will assure that the Clinical Supervisor has 10 or fewer clients. |
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.
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Observations
Based on a review of 14 client records, the facility released information from patients records using consent to release information forms that did not include all of the required information in two of 14 records reviewed. Patient #6 was admitted for partial hospital treatment on April 4, 2018, and discharged from partial hospital treatment on May 21, 2018. The facility sent a letter dated April 16, 2018, to Patient #6's probation department. The name and address for the patient's probation department was written over whited out text on the consent to release information form dated April 16, 2018. Patient #9 was admitted for outpatient treatment on January 26, 2018, and discharged from outpatient treatment on June 27, 2018. The facility billed the patient's insurance for treatment services during the patient's treatment. The consent to release information form for the patient's insurance provider dated January 26, 2018, did not include a witness signature. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Retraining of assessment staff regarding confidential release forms was conducted on 9-4-18 by the Program Director.
All staff were informed during that training that they cannot use white out on any consent form document.
Requirements of a valid consent including a witness signature was reviewed with staff during the training on 9-4-18.
Consent forms are now being reviewed by the newly hired assessment supervisor to be sure that errors such as not getting a witness signature are caught and corrected. The Assessment Supervisor reviews at least 50% of the new admissions each week ongoing. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The facility failed to ensure that it notified patients of their rights to appeal a decision to limit patients' access to their patient records. A total of sixteen patients records were reviewed during the on-site inspection. Fourteen applicable records did not have the required documentationPatient records #1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 13, 14, 15 and 16 were missing the required documentation.. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Notification to clients that they have the right to appeal a decision limiting their access to their records to the director is being added to the client handbook which is currently under revision and will be completed by 10-31-18. The Assessment Supervisor and Program Director are responsible to complete the handbook revision. This handbook is reviewed and given to all clients as part of our admission process.
This citation was reviewed by the Program Director with all staff at our weekly staff meeting on 8-23-18. Until the handbook is revised, the clients are being informed of this right verbally. |
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
The facility failed to ensure that it updated patient treatment plans at least once every 60 days in 4 of 6 applicable outpatient records. Patient #8 was admitted for outpatient treatment on August 30, 2017, and discharged from outpatient treatment on April 20, 2018. The patient's individualized treatment plan was dated September 15, 2017, but the treatment plan was never updated. Patient #10 was admitted for outpatient treatment on December 15, 2017, and discharged from outpatient treatment on June 5, 2018. The patient's individualized treatment plan was dated February 15, 2018, but the treatment plan was not updated until May 14, 2018. Patient #11 was admitted for outpatient treatment on January 10, 2018, and discharged from outpatient treatment on May 7, 2018. The patient's individualized treatment plan was dated January 23, 2018, but the treatment plan was not updated until April 24, 2018. Patient #12 was admitted for outpatient treatment on April 13, 2017, and discharged from outpatient treatment on June 5, 2018. The patient's individualized treatment plan had an update completed on December 28, 2017, but the patient's treatment was not updated again until April 3, 2018. These findings were reviewed with the facility staff as part of the inspection process.
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Plan of Correction
Retraining of Clinical Staff on the timing and completion of treatment plans and updates was conducted by the Clinical Supervisor on 9-27-18.
The Clinical Supervisor has created a calendar of treatment plan due dates in order to monitor and assure staff completion on a timely basis. She is checking the records where treatment plans are due ongoing on a weekly basis.
In addition, 10 random chart audits are being reviewed weekly by the supervision team (Program Director, Clinical Supervisor & Assessment Supervisor) to monitor the timely completion of required documentation. |