INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 11, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pyramid Harrisburg 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:
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Plan of Correction
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document a psychosocial evaluation within its policy timeframe in four out of seven records reviewed. The facility's policy is that the psychosocial evaluation will be completed within twenty-four hours of admission.
Client #2 was admitted on February 20, 2025, and was still active at the time of the inspection. Based on the facility's policy, the psychosocial evaluation should have been completed no later than February 21, 2025; however, it was completed on February 23, 2025.
Client #3 was admitted on March 11, 2025, and was still active at the time of the inspection. Based on the facility's policy, the psychosocial evaluation should have been completed no later than March 12, 2025; however, it was completed on March 16, 2025.
Client #4 was admitted on December 27, 2024, and was discharged on February 3, 2025. Based on the facility's policy, the psychosocial evaluation should have been completed no later than December 28, 2024; however, it was completed on December 31, 2024.
Client #6 was admitted on January 28, 2025, and was discharged on March 13, 2025. Based on the facility's policy, the psychosocial evaluation should have been completed no later than January 29, 2025; however, it was completed on January 30, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will retrain all staff on documentation time lines during partial hospitalization (PHP) weekly meeting on 4/29.
Executive director will utilize program's assessment tracker to cross reference when documentation needs to be completed. ED will review tracker daily to ensure psychosocial evaluations are being completed and signed on time.
Executive director will review staffing patterns to ensure staff have appropriate time to complete all assessments.
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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
Based on a review of partial hospitalization client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of two applicable records reviewed.
Client #2 was admitted on February 20, 2025, and was still active at the time of the inspection. A treatment plan was completed on March 4, 2025, and the next update was due no later than April 4, 2025; however, the next update was completed on April 7, 2025.
Client #6 was admitted on January 28, 2025, and was discharged on March 13, 2025. A treatment plan was completed on February 7, 2025, and the next update was due no later than March 7, 2025; however, there were no further treatment plan documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director and clinical supervisor implemented weekly partial hospitalization meetings to review upcoming documentation due dates. Weekly meeting has been instated on 4/22. ED and CS will utilize the treatment plan tracking sheet which will provide when treatment plan and updates are due.
Clinical supervisor will be assigned all staff that complete treatment plans so alerts will also be sent to her and she can review weekly in the EMR.
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709.82(c) LICENSURE Treatment and rehabilitation services
709.82. 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 partial hospitalization client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of seven records reviewed.
Client #1 was admitted on March 10, 2025, and was still active at the time of the inspection. The treatment plan dated March 19, 2025, indicated five group therapy sessions and two individual sessions per week. During the week of March 30-April 5, 2025, only four group sessions were documented and only one individual session was documented.
Client #3 was admitted on March 11, 2025, and was still active at the time of the inspection. The treatment plan dated March 19, 2025, indicated two individual sessions per week. During the week of March 30-April 5, 2025, only one individual session was documented.
Client #6 was admitted on January 28, 2025, and discharged on March 13, 2025. The treatment plan dated February 7, 2025, indicated two individual sessions per week. During the week of February 9-February 15, 2025, only one individual session was documented.
Client #7 was admitted on December 9, 2024, and discharged on January 7, 2025. The treatment plan dated December 13, 2024, indicated five group therapy sessions and two individual sessions per week. During the week of December 22-December 28, 2024, no group or individual sessions were documented. Additionally, during the week of December 29, 2024-Janaury 4, 2025, only two group sessions were documented and no individual sessions were documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff will be retrained during weekly staff meeting on 4/29 on the importance of same day outreach calls being implemented and documented in the EMR for missed group sessions.
Executive director will spot check monthly to ensure these items are present in the electronic medical record. |
709.82(d)(1) 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:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of partial hospitalization client records, the facility failed to provide counseling to a client at least twice weekly.
Client #1 was admitted on March 10, 2025, and was still active at the time of the inspection. During the week of March 30-April 5, 2025, only one individual session was documented.
Client #3 was admitted on March 11, 2025, and was still active at the time of the inspection. During the week of March 30-April 5, 2025, only one individual session was documented.
Client #6 was admitted on January 28, 2025, and discharged on March 13, 2025. During the week of February 9-February 15, 2025, only one individual session was documented.
Client #7 was admitted on December 9, 2024, and discharged on January 7, 2025. During the weeks of December 22-January 4, 2025, no individual sessions were documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff will be retrained during weekly staff meeting on 4/29 on the importance of documenting cancelled or re-scheduled individual sessions with a reason and reschedule date if appropriate.
Executive director will review sample records monthly to ensure these items are being documented in the electronic record. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of partial hospitalization client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of four discharged records reviewed. The facility's policy to initiate a follow-up contact within seven days for all discharge types.
Client #4 was admitted on December 27, 2024, and was discharged on February 3, 2025. There was no documentation of a follow-up in the client record.
Client #5 was admitted on October 21, 2024, and was discharged on November 14, 2024. There was no documentation of a follow-up in the client record.
Client #7 was admitted on December 9, 2024, and was discharged on January 7, 2025. There was no documentation of a follow-up in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be retrained during weekly staff meeting on 4/29 on the importance of follow up discharge phone calls.
Staff will alert executive director and clinical supervisor of a discharge so that it can be tracked. ED and CS will put the client on tracker sheet to ensure a phone call is being send out within 7 days of discharge.
ED and CS will also review in weekly PHP meetings when a client is in need of a follow up and the staff member will complete and document.
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