INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15-16, 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 17, 2008.
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Plan of Correction
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705.7 (b) (2) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on the physical plant inspection conducted on October 15 and 16 , 2008, the facility failed to ensure the cleanliness of food preparation and dining areas .FINDING: The floors in the kitchen and dining areas were not clean. The floor surfaces in the kitchen and dining areas are badly worn and have gaps and breaks in them which inhibit proper cleaning and disinfecting.
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Plan of Correction
Program Director submitted a Capital Budget request to Director of Physical Plant Development that the kitchen/dining room floor be replaced using a sturdy indoor/outdoor carpet. This was approved and will be implemented by the maintenance staff. |
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 four client records during the onsite licensing inspection held October 15-16, 2008, the facility failed to consistently obtain consent prior to releasing client identifying information in two of four client records where required.FINDING: Client identifying information from client records # 2 and 3 was released to the Single County Authority when there was no documentation of the clients' consents to allow for such a release of information.
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Plan of Correction
Clinical Supervisor and Assistant Director of Nursing will conduct an in-service training with their staff regarding the use of proper releases and the appropriate completion of consents. In-serviced will include education on the meaning of "informed" consent. Clinical Supervisor and Assistant Director of Nursing will ensure compliance with this standard through ongoing monthly clinical supervision with the secretaries and direct care staff, and monthly chart monitors. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of four client records during the onsite licensing inspection held October 15-16, 2008, the facility failed to consistently adhere to the limitations established at 4 Pa. Code Subsection 255.5(b) when making releases of client identifying information in three of four client records where required.FINDING: Client records # 1, 2 and 3 contained documentation of consents to release information where the specific information listed for release exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b) or failed to identify what specific pieces of client identifying information would be released.
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Plan of Correction
Clinical Supervisor and Assistant Director of Nursing will conduct an in-service training with their staff regarding the use of proper releases and the appropriate completion of consents. In-serviced will include education on the meaning of "informed" consent, importance of completing all sections of each consent, and the appropriate use of the line item "Other". Clinical Supervisor and Assistant Director of Nursing will ensure compliance with this standard through ongoing monthly clinical supervision with the secretaries and direct care staff, and monthly chart monitors. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of four client records during the onsite licensing inspection conducted on October 15-16, 2008, the facility failed to document complete personal histories in three of four client records where required.FINDING:Personal histories were incomplete in client records # 1, 3 and 5. The legal history was incomplete in client records # 1 and 5. Family and employment histories were incomplete in client records # 1 and 3.
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Plan of Correction
Director of Nursing will conduct an in-service training with the staff regarding focus on addressing all issues and details in the admissions data of the psychosocial assessment, including legal, family, and employment histories. Program Director will ensure compliance with this standard through ongoing monthly chart monitors. |
709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of four client records during the onsite licensing inspection held October 15-16, 2008, the facility failed to consistently document complete, legible progress notes in two of four client records where required.FINDINGS: Progress notes were illegible in client records # 2 and 4. Group progress notes in client records # 1, 2, 3 and 4 were recorded on standardized forms that use a checkoff format and include a narrative section for the counselor to document details of the sessions. The group progress notes documented on these standardized forms did not address what the topic of each group was and did not document an assessment of the group dynamics.
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Plan of Correction
The Clinical Supervisor will conduct an in-service training with the clinical team, providing instruction on clinical documentation of group therapy sessions, including the general topic of the session and the interactions of group members. Clinical Supervisor will follow-up with regular individual and group supervision with the clinical staff. The Program Director will be responsible for ongoing compliance with this standard via monthly chart monitors. In addition, Pyramid Healthcare has begun the process of using Electronic Medical Records in the last few months and, until the entire clinical section of the client chart is computerized, emphasis will be placed on legibility of hand-written records with all staff. |