INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 31 & November 1, 2011 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of employee personnel and training records, the facility failed to document monthly supervisory meetings for the new clinical supervisor for the first six months of employment.
The findings include:
Based on the review of employee personnel and training records on October 4-5, 2011, and a discussion with the facility director on November 1, 2011, there is no documentation of monthly supervisory meetings for employee #3
This was discussed with and confirmed by the facility director on November 1, 2011.
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Plan of Correction
Beginning immediately, the Program Director will provide documented monthly clinical supervision meetings with the Clinical Supervisor. This will be monitored by the VP of Adolescent Services. Full compliance will be met by April 2012. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs, the facility failed to document the completion of monthly unannounced fire drills.
The findings include:
Fire drill logs were reviewed on November 1, 2011 for the time period of October 2010 to October 2011. There was no documentation that a fire drill was conducted for the months of April 2011 and September 2011.
This was discussed with the facility director on November 1, 2011, who confirmed that there was no documentation of a fire drill in April 2011 and September 2011.
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Plan of Correction
Beginning immediately, Fire Drills will be conducted monthly and within the required time frames. All documentation will be reviewed by the Risk Committee at monthly meetings to ensure compliance. Program Director will ensure compliance. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the specific information to be disclosed and the purpose of disclosure in three of four client records.
The findings included:
Four client records were reviewed on October 31, 2011. Four client records required an informed and voluntary consent from the client; including the specific information to be disclosed and the purpose of disclosure. The facility failed to obtain an informed and voluntary consent from the client; including the specific information to be disclosed and the purpose of disclosure in client records # 1, 2, and 4.
Client record #1 - The client was admitted to treatment on 9-23-11. The client record included a consent to release information form for the Juvenile Probation Office, which was signed on 9-23-11. There was no documentation in the client record that the client had been adjudicated delinquent or dependent. The specific information to be released, listed on the form, exceeded the limitations on the amount of information that could be released at 4 Pa. Code subsection 255.5(b), and allowed for the disclosure of the client history and physical examination, discharge summary/aftercare plan, medication administration records, and the psychosocial evaluation. In addition, the purpose section of the disclosure indicated non-relevant reasons for this disclosure. The reasons indicated included psychiatric evaluation, family involvement and emergency contact which are not the functions of the Juvenile Probation Office.
Client record #2 - The client was admitted to treatment on 10-10-11. The client record had a consent to release information form for the Primary Care Physician which was signed on 10-10-11. There was no purpose for the disclosure of information documented on the release form.
Client record #4 - The client was admitted to treatment on 8-15-11 and was discharged on 10-3-11. The client record had three separate consent to release information forms to family members which were signed on 8-15-11. All three releases of information did not include documentation of the specific information to be disclosed and did not include a purpose for the disclosure.
On October 31, 2011, the facility director confirmed that the consents to release information forms in client records #1, 2, and 4 did not include an informed and voluntary consent.
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Plan of Correction
All pertinent staff members will be re-trained on Pa.Code subsection 255.5 as well as informed and voluntary consent by February 1, 2012. All consents will be individually reviewed during monthly audit to ensure compliance. Program Director will monitor. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document when the case consultations were completed in three of four client records.
The findings include:
Four client records were reviewed on October 31, 2011. Case consultations were required in four client records. The facility policy states case consultations are due within seven days of admission then every 90 days thereafter. The facility did not document when the case consultations were completed in client records # 2, 3, and 4 .
Client record #2 - The client was admitted to treatment on 10-10-11. A case consultation was documented, but did not include the date of completion. It could not be determined if the case consultation was completed within the facility policy and procedure time frame.
Client record #3 - The client was admitted to treatment on 7-20-11 and discharged on 9-1-11. A case consultation was documented, but did not indicate a date of completion. It could not be determined if the case consultation was completed within the facility policy and procedure time frame.
Client record #4 - The client was admitted to treatment on 8-15-11 and discharged on 10-3-11. A case consultation was documented, but did not include a date of completion. It could not be determined if the case consultation was completed within the facility policy and procedure time frame.
The facility director and lead counselors confirmed this on October 31, 2011.
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Plan of Correction
EHRS system will be updated to include a date of completion for case consultations. All counselors will be re-trained by January 1, 2012. Lead counselors to monitor compliance through monthly open chart audits. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document the date of completion of the discharge summary in two of two client records reviewed.
The findings include:
Four client records were reviewed on October 31, 2011. Discharge summaries were required to be documented in two of the client records. Discharge summaries are required to be documented within one week of discharge. Two of two discharge summaries did not include documentation of the completion date, therefore, it could not be determined if they were completed within the one week time frame.
Client record #3 - The client was admitted to treatment on 7-20-11 and discharged on 9-1-11. The discharge summary was due by 9-8-11. The discharge summary was documented, but it did not include the date it was completed.
Client record #4 - The client was admitted to treatment on 8-15-11 and discharged on 10-3-11. The discharge summary was due by 10-10-11. The discharge summary was documented, but it did not include the date it was completed.
The facility director and lead counselors confirmed that the discharge summaries did not have the date of completion documented on October 31, 2011.
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Plan of Correction
All counselors will be re-trained on the importance of providing a completion date for discharge/treatment summaries by January 1, 2012. Form will be revised to include completion date as well. Lead Counselors will ensure compliance through monthly chart audits. |