INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21-22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramis Healthcare Inc, Erie Outpatient 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 and a plan of correction is due on November 19, 2008.
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Plan of Correction
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on an inspection of the physical plant on October 22, 2008, the facility failed to maintain hot water under pressure and failed to maintain hot water temperatures not exceeding 120 degrees.
Findings:
The hot water temperature tested at 132 degrees. In one of the two men's bathrooms, the hot water tap had no running water, therefore no hot water was available.
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Plan of Correction
Director will schedule a meeting with the Landlord by 11/28/08 to have the water temperature turned down or/and have the water heater replaced. Program Director will maintain water temperature by checking monthly and documenting in the fire/risk log.
Hot water has been turned back on in the East bathroom. Repairs on the plumbing were completed on 10/24/08.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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
Based on the review of the facility's fire drill logs on October 21-22, 2008, the facility failed to maintain a written fire drill record that included the exit route used and whether the fire alarm or smoke detector was operative.
Findings:
The exit route used and whether the fire alarm or smoke detector was operative were not documented for the months of June, July, August, September and October of 2008.
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Plan of Correction
Plan of Correction:
The Risk Coordinator has begun to document the date each smoke detector was test and document the alternitive route used monthly in the modified fire log paper work as part of the fire drill process. Program Director will monitor monthly at the risk meeting.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill logs on October 21-22, 2008, the facility failed to maintain a written fire drill record that included the exit route used.
Findings:
The exit route used was not documented for the months of June, July, August, September and October of 2008.
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Plan of Correction
Program Director and Risk Coordinator have developed a key that has been added to the fire drill log that identifies what door was used for evacuation. Program Director will monitor in monthly risk meeting. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill logs on October 21-22, 2008, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
Findings:
The fire drill log indicated that since January 2008, of the ten drills conducted, six took place between the hours of 3 and 5 PM.
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Plan of Correction
Risk Coordinator has developed a monthly alternating schedule that rotates the shift times and days of the week that the fire drills will occur. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of the facility's fire drill logs on October 21-22, 2008, the facility failed to maintain a written fire drill record that included whether a fire alarm or smoke detector had been set of during each fire drill.
Findings;
There was no documentation in the fire drill logs that a fire alarm or smoke detector was set off during fire drills for the months of June, July, August, September and October, 2008.
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Plan of Correction
Plan of Correction:
Risk Coordinator will document in the fire log what smoke detector was used to sound off the fire drill. Program Director will monitor at monthly risk meetings.
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709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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
Based on the review of seventeen client records on October 21-22, 2008, six where reviewed as Partial Hospitalization records. The facility failed to develop an individual treatment and rehabilitation plan in two of six client records where required.
Findings:
The individual treatment and rehabilitation plans were identical in that, the long and short terms goals, objectives and support services were the same in client records # 1 and 2. There were no individual goals, objectives or support services listed for the clients.
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Plan of Correction
Plan of Correction: Lead Counselor and Program Director have scheduled a 1.0 hr. training on 11/20/08 to train all new staff and review with all Clinical Staff how to Develop an individual treatment Plan. All staff will develop a sample plan that will be shared and feedback given to insure compliance. Program Director will monitor compliance with monthly chart monitors. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of seventeen client records on October 21-22, 2008, six where reviewed as Partial Hospitalization records. The facility failed to document an individual treatment and rehabilitation plan with short and long-term goals for treatment as formulated by both staff and the client in two of six client records where required.
Findings:
The short and long term goals listed were identical in client records # 1 and 2. There were no individual long or short term goals developed.
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Plan of Correction
Lead Counselor and Program Director have scheduled a 1.0 hr. training on 11/20/08 to train new staff and review with all Clinical Staff how to Develop an individual treatment Plan. This will include reviewing short and long term goals. All staff will develop a sample plan that will be shared and feedback given to insure compliance. Program Director will monitor compliance with monthly chart audits. |
709.83(a)(6) 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:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of seventeen client records on October 21-22, 2008, six client records where reviewed as Partial Hospitalization records. The facility failed to document a complete aftercare plan in one of one client record where required.
Findings:
The aftercare plan in client record #4 was missing time frames for the objectives identified in the aftercare plan. The plan was also missing a contact person. The plan had been completed by the client. There was no clinical assessment of the client's aftercare needs.
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Plan of Correction
Lead Counselor and Program Director have scheduled a training on 12/4/08 to address with all Clinical staff the proper way to complete and review an aftercare plan. Program Director will complete a change of forms request to the forms committee by 12/4/08. This request will be to add a line for a Counselor contact person. Once the new form is approved by the forms committee, Program Director will provide all Clinical staff with an updated version of the aftercare plan and a review in the Clinical staff meeting. |
709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on the review of seventeen client records on October 21-22, 2008, the facility failed to document that the client was informed of the right to appeal a decision limiting access to his records to the project director in seventeen of seventeen records where required.
Findings:
There was no documentation that the client had been informed of this right in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17.
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Plan of Correction
OPC Director has submitted the request to make the necessary changes on the Client Rights form to the forms committee to include Clients right to appeal a decision to limit access to his/her records to the project director.
Once the forms committee had made the necessary changes to the form, Program Director will review changes with all clinical staff at a staff meeting by 3/13/09 and insure that all old forms are removed. Program director will monitor through monthly chart monitors.
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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
Based on the review of seventeen client records on October 21-22, 2008, eleven where reviewed as Outpatient records. The facility failed to update the treatment and rehabilitation plans at least every sixty days in eight of eight client records where required.
Findings:
For clients attending Intensive Outpatient levels of care and then Outpatient levels of care, the facility was completing a new treatment plan in place of the treatment plan updates required every 60 days. The new treatment plans did not review and update the goals identified on the original treatment plan, nor was there a discussion of the clients' progress or lack of progress in client records # 9, 10, 11, 12, 13 and 14.
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Plan of Correction
Program Director will schedule a time to meet with the other OP Program Directors at Pyramid by 12/31/08. We will develop samples treatment plan update and instructions on how to complete a treatment review.
Program Director will then schedule a staff training by 1/15/09. All Clinical staff will attend the training. Program Director will monitor compliance in monthly chart reviews.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of seventeen client records on October 21-22, 2008, eleven where reviewed as Outpatient records. The facility failed to document a complete aftercare plan in two of two client records where required.
Findings:
The aftercare plans in client records # 14 and 16 did not include time frames for objectives identified in the aftercare plan. The plans also failed to document a contact person. The aftercare plans had been completed by the clients. There were no clinical assessments of the clients aftercare needs.
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Plan of Correction
Program Director have scheduled a training on 12/4/08 to address with all Clinical staff the proper way to complete and review an aftercare plan. Program Director will complete a change of forms request to the forms committee by 12/4/08. This request will be to add a line for a Counselor contact person. Once the new form is approved by the forms committee, Program Director will provide all Clinical staff with an updated version of the aftercare plan and a review in the Clinical staff meeting. |