INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13, 2017 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Nine personnel records were reviewed on November 8, 2017, for the licensing renewal inspection that was conducted on November 13, 2017. The facility failed to provide documentation for the completion of HIV/AIDS training within the required time period for employee record # 4.
Employee # 4 was hired by the facility on 9/30/15 and began employment in the counselor assistant position on 4/25/16. The employee was then promoted to the counselor position on 4/25/17. The employee was required to complete HIV/AIDS training by no later than 4/25/17. The provision of this training was not documented in the employee's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director held a meeting with the management team on 12/19/17 and reviewed the staff development qualifications which will be added to our New Hire Orientation process.
Employee #4 completed the HIV/AIDS training on 12/21/17 which was documented in her personnel file. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Fire drills were reviewed on November 13, 2017, for the period of January 2017 - September 2017. Written records for monthly fire drills conducted on the following dates did not specify the number of persons in the facility during the drills: 1/31/17, 2/28/17, 3/28/17, 4/25/17, and 5/31/17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address this area of concern a new Corporate wide Fire Drill form was revised to include the numbers of persons located in the facility during the Fire Drill. The form was revised by the Corporate RISK Department in June 2017 and distributed to all Pyramid locations.
Corrected written Fire Drill records were noted by the licensing inspector beginning with June 2017. |
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
Eight client records were reviewed on November 13, 2017. The facility failed to obtain an informed and voluntary consent to release information that did not exceed the limitations imposed in 4 Pa. Code 255.5 (b) for client records # 2 and 4.
Client # 2 was admitted into treatment on 9/18/17 and was still active in treatment. A consent to release information to a medical assistance provider, signed and dated by the client on 9/18/17, authorized the release of the following information: medication administration record, history and physical, and psychiatric evaluation.
Client # 4 was admitted into treatment on 7/11/17 and was still active in treatment. A consent to release information to an insurance company, signed and dated by the client on 7/11/17, authorized the release of the following information: medication administration record, history and physical, and psychiatric evaluation.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address this area of concern, the management team met on 12/19/17 to discuss proper completion of informed and voluntary consents. As a result, the Mobile Assessor/Intervention Coordinator developed an Information for Release Guide to train and distribute. The Mobile Assessor/Intervention Coordinator will hold a training for the clinical and assessments teams on 1/17/18 and review the above Information to Release Guide.
Ongoing review and training will occur in individual supervisor and will be provided by both the Clinical Supervisor and the Mobile Assessor/Intervention Coordinator.
For Clients #2 and #4, the consents to release information were revised. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
A licensing renewal inspection was conducted on November 13, 2017. Based on a review of client records, and an interview with facility staff, the facility failed to report to the Department the death of a client. The client's death occurred at their home on 5/12/17, and the client was discharged on 5/15/17 after the incident was reported to the facility.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address this area of concern, the facility Director developed a procedure when an unusual incident occurs at the facility. The procedure will include the completion of both internal and external incident reports and notifications.
The facility Director reviewed this procedure with the entire management team on 12/19/17 in the event that the Director is absent during an unusual incident. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Three client records were reviewed for the partial hospitalization activity on November 13, 2017. The facility failed to document a treatment plan update at least every 30 days for client record # 2.
Client # 2 was admitted into treatment on 9/18/17 and was still active in treatment. A comprehensive treatment plan was completed for the client on 9/19/17. A treatment plan update was due to be completed by 10/19/17, and one was not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to address this area of concern, the Clinical Supervisor and Program Director developed an internal auditing tool to better track clinical documentation, including treatment plan review dates. The auditing tool was introduced and reviewed with the clinical team on 12/20/17. The Clinical Supervisor will conduct monthly internal chart audits beginning 1/8/18 and continue to monitor and review during individual supervision meetings.
Client #2 treatment plan will be updated on 1/8/18.
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709.82(d) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
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Observations
Three client records were reviewed for the partial hospitalization activity on November 13, 2017. The facility failed to document the provision of individual counseling at least twice weekly for client records # 1 and 2.
Client # 1 was admitted into treatment on 8/28/17 and was still active in treatment. Documentation in the client's record indicated that the client attended individual counseling sessions on the following dates: 8/28/17, 8/29/17, 8/30/17, 8/31/17, 9/1/17, 9/20/17, 9/26/17, 9/29/17, 10/16/17, and 10/30/17.
Client # 2 was admitted into treatment on 9/18/17 and was still active in treatment. Documention in the client's record indicated that the client attended individual counseling sessions on the following dates: 9/18/17, 10/10/17, and 11/6/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This area of concern was addressed on 12/19/17 when the Clinical Supervisor developed an internal individual counseling schedule specifically for the clients in the Partial program. The Clinical Supervisor holds a consistent supervision meeting with the Partial counselors and has developed a consistent treatment schedule to include two weekly individual counseling sessions for each Partial client.
Continued monitoring will be conducted weekly by the Clinical Supervisor. |
709.83(a) LICENSURE Client records
709.83. 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:
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Observations
Three client records were reviewed for the partial hospitalization activity on November 13, 2017. The facility failed to document a complete client record for client record # 3.
Client # 3 was admitted into treatment on 4/25/17 and was discharged on 6/15/17. A discharge summary was not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
This area of concern was addressed during the transition of our new Corporate electronic medical record system on 7/1/17. The new electronic medical record system now includes an electronic discharge documentation bundle which assists clinicians in completing all necessary discharge summary documentation.
The Clinical Supervisor will continue to monitor clinical documentation and completed client records through the new internal chart audit system which will be implemented on 1/8/18.
Client #3 discharge summary will be completed by 1/8/18. |
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
Three client records were reviewed for the outpatient activity on November 13, 2017. The facility failed to document a treatment plan update at least every 60 days for client records # 4 and 6.
Client # 4 was admitted into treatment on 7/11/17 and was still active in treatment. The first treatment plan update documented in the client's record was completed on 8/24/17. A subsequent treatment plan update was then completed on 11/1/17.
Client # 6 was admitted into treatment on 3/6/17 and was discharged on 6/6/17. A comprehensive treatment plan was completed for the client on 3/17/17. A treatment plan update was then completed on 5/30/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This area of concern was addressed when the Clinical Supervisor and Program Director met on 12/19/17 in order to create an internal chart audit system in order to more closely monitor client records. The Clinical Supervisor reviewed this information with the clinical team during a staff meeting on 12/20/17 and internal chart audits will be completed by the Clinical Supervisor on a monthly basis beginning 1/8/18.
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709.93(a) 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:
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Observations
Three client records were reviewed for the outpatient activity on November 13, 2017. The facility failed to document a complete client record for client record # 6.
Client # 6 w as admitted into treatment on 3/6/17 and was discharged on 6/6/17. A discharge summary and follow-up information was not found in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This area of concern was addressed in collaboration with the same results found in Observation #:1593. As a result, the new Corporate electronic medical record system now includes a discharge bundle in an effort to prompt clinicians to complete discharge summaries in a more timely manner. The new electronic medical record system was incorporated on 7/1/17 and the clinical staff received training and supervision. The Clinical Supervisor will continue to monitor the client records for completeness through monthly internal chart audits beginning 1/8/18.
Client #6 discharge summary and follow-up information will be completed on 1/8/18. |
709.42(b)(2) LICENSURE Preliminary Treatment Plan
709.42. Project management.
(b) The intake project or treatment service providers shall have a written procedure for the performance of the following functions:
(2) Preparation of a preliminary treatment plan utilizing appropriate available service resources and listing the services to be provided. This plan shall be developed in cooperation with and agreed to by the intake project or treatment service provider and the client. The service plan shall also include referral to services not specifically for drug and alcohol clients; for example, legal services and dental services for which the client may be eligible.
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Observations
Two client records were reviewed for the intake, evaluation, and referral activity on November 13, 2017. The facility failed to document a preliminary treatment plan for client records # 7 and 8.
Client # 7 received an evaluation and referral for treatment services on 8/25/17.
Client # 8 received an evaluation and referral for treatment services on 8/3/17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
This area of concern was addressed through the inception and ongoing stages of the new corporate electronic medical record system which went "LIVE" on 7/1/17. Initially, the preliminary treatment plans were not included in the intake and evaluation bundles of the new electronic medical record system. As a result, a preliminary treatment plan process was developed internally by the Regional Clinical Coordinator where a training will be conducted during staff meeting on 1/17/18. The Clinical Supervisor will continue to train and develop new incoming clinicians during New Hire Orientation. Lastly, internal chart audits will be conducted by the Clinical Supervisor on a monthly basis beginning 1/8/18. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Two client records were reviewed for the intake, evaluation, and referral activity on November 13, 2017. The facility failed to document a consent to treatment for client record # 7.
Client # 7 received an evaluation and referral for treatment services on 8/25/17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
This area of concern was addressed during the management team meeting on 12/19/17. The Mobile Assessor/Intervention Coordinator developed an Information for Release Guide and will provide a training on consents to the clinical and assessment teams on 1/17/18. Ongoing training and monitoring will continue during individual supervision sessions held by both the Clinical Supervisor and the Mobile Assessor/Intervention Coordinator. |