INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21 through 22, 2008 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 and a plan of correction is due on November 24, 2008.
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Plan of Correction
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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 five client records on October 21, 2008, the facility failed to obtain an informed and voluntary consent to release information in one of four client records where required.Findings:Client record # 1 contained a consent to release information form that was signed by both then client and a witness, but the form was otherwise blank.
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Plan of Correction
Program Director will hold an in-service for all primary care staff in order to review and educate on the correct procedures when filling out consents and having clients sign them. The in-service will include education on the meaning of "informed" consent and the importance of ensuring that each section of the consent is filled out in its' entirety. Program Director will ensure compliance with this standard through monthly supervision and monthly chart monitor. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on the review of five client records on October 21, 2008, the facility failed to document follow-up information in two of three client records where required..Findings:The facility failed to document follow-up information in client records # 4 and 5.
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Plan of Correction
Program director will change the follow-up process. The newly hired Administrative Assistant will be trained on how to do follow-up calls when clients are discharged and document these calls on the Aftercare Plan. The counselors will be instructed to give the client's Aftercare Plan to the Administrative Assistant who will make the follow-up call seven days from the discharge date. Compliance for this standard will be monitored by the Program Director via monthly supervision and monthly chart monitor. |