INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted February 22-23, 2023, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pyramid Healthcare, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on observation during a complaint investigation conducted on February 22-23, 2023, the facility failed to maintain counseling areas with furnishings in good repair.
Four worn/torn chairs were observed in the group counseling room near the exit door on the first floor.
This was discussed with the Facility Director during the complaint investigation.
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Plan of Correction
Starting April 2023, the integrity and quality of all furniture throughout the building will be assessed on already established facility walk-throughs. This new item will be added to the log of items checked/areas inspected. Furniture with torn fabrics or compromised in any other way will be disposed of upon discovery, and replacements will be ordered the same day. This will occur monthly and facility walk-through which will now include furniture inspections are conducted by the Maintenance Manager with oversight from the ED to ensure routine monthly walk-throughs are conducted as well as ensuring each item on the walk-through log is completed. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records during a complaint investigation conducted February 22-23, 2023, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in one of the four records reviewed.
Client #2 was admitted to the detoxification activity on September 17, 2022 and discharged on September 22, 2022. He was admitted to rehabilitation and treatment activity on September 22, 2022 and discharged on December 20, 2022.
His treatment and rehabilitation plan dated October 26, 2022 and November 23, 2022 both indicated that the client would receive group therapy five times per week and individual therapy daily.
Chart documentation showed that the client did not receive individual therapy on a daily basis, but instead it occurred on a weekly basis. In addition, no individual therapy was provided during the weeks of November 4, 11, and 22, of 2022.
This was discussed with the Facility Director during the complaint investigation.
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Plan of Correction
1. Clinical director will conduct group supervision with the clinical team and review specifically documentation within this observation #1773. Included will be; scheduling individual sessions on EMR calendar, 24-hour due date from time of service rendered, and attention to detail of selecting correct options in drop-down menus. Additionally, the regulation that states the services received must match what is listed in the treatment plan will be reviewed to reinforce the importance of making correct selections.
2. Monthly chart monitoring of 20 charts takes place to review and monitor the frequency of individual session occurrences, documentation completion, and documentation quality. This is to ensure regular compliance with receipt of services offered at the 3.5 LOC within an individuals treatment episode. |