INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Chambersburg 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel/training records, the facility failed to document that each counselor completed at least 25 clock hours of training annually in one of three personnel/training records.The findings include:Three counselor personnel/training records were reviewed on September 1, 2015 and September 10, 2015. The last completed training year reviewed was for the period of January - December 2014. Two of the counselors reviewed were new hires. Twenty-five clock hours of annual training was required in one counselor record. Twenty-five clock hours of annual training was not documented in personnel/training record # 3. Employee # 3 became a counselor on 9/30/13 and had 18 hours of training documented for the 2014 training year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
With the hiring of the current Director in March of 2015, a staff training grid was composed. This tool documents trainings received and hours still needed for each staff member per year. This tool is reviewed monthly with each staff member to monitor progress on training hours for the year.
As to date, all staff have obtained required amount of training hours for 2015. This tool will continue to be used to ensure compliance with training regulation. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the facility failed to maintain a photograph of each patient, which includes the patient's name and birth date, in two of two Buprenorphine patient records reviewed. The findings include: Two patient records were reviewed on September 10, 2015. Both patient records were required to include a photograph of each patient, which includes the patient's name and date of birth. Patient records # 1 and 2 did not include documentation of a photograph or identification which included the patient's name and date of birth.Patient # 1 was admitted into treatment on 3/9/15 and was still active at the time of the inspection. The patient was initially given a prescription for Suboxone on 4/8/15. There was no photograph or identification, which included the patient's name and date of birth, in the patient's record.Patient # 2 was admitted into treatment on 6/9/15 and was still active at the time of the inspection. The patient was initially given a prescription for Suboxone on 6/17/15. There was no photograph or identification, which included the patient's name and date of birth, in the patient's record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patient records for the Buprenorphine program were transferred to an electronic system in 4/2015. The process previously used for obtaining photo id was changed as of 9/11/15.
All clients requesting admission into the Suboxone program must provide Administrative Assistant with photo ID. The Nurse then verifies retention of the photo ID before scheduling client for induction. This new process has ensured that all clients currently in program have a photo ID on file.
Retention of client's photo ID has also been added to monthly chart audit tool so that the Director can monitor continued compliance. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of client records, the facility failed to document that the patient received an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, which included 1 hour of individual psychotherapy in two of two Buprenorphine patient records reviewed. The findings include: Two patient records were reviewed on September 10, 2015. Both patient records required documentation of an average of 2.5 hours of psychotherapy per month, which included 1 hour of individual psychotherapy. There were no documentation of 1 hour of individual psychotherapy in patient records # 1 and 2. Patient # 1 was admitted into treatment on 3/9/15 and was still active at the time of the inspection. There was no documentation of 1 hour of individual psychotherapy for the months of April, May, June, and August 2015.Patient # 2 was admitted into treatment on 6/9/15 and was still active at the time of the inspection. There was no documentation of 1 hour of individual psychotherapy for the months of June and July 2015. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff was educated on 9/11/15 that client's in Bup. program must be seen for 2.5 hours per month and that 1 hour of that must be an individual session.
All client's charts were reviewed for 1 hour requirement on 9/11/15. Any clients not yet receiving 1 hour of individual for month were scheduled. As of 10/1/2015, all clients in program were seen for 1 individual hour for September.
Each counselor now has an individualized tracking sheet to utilize with Bup. clients. It will reflect compliance with 1 hour of individual and overall 2.5 hours of treatment.
Tracking of individual sessions was added to the monthly chart audit tool for the program. This will allow the Director to monitor ongoing compliance. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was documented upon intake and assessment in two of five client records.The findings include:Five client records were reviewed on September 10, 2015. All records were reviewed for individualized treatment and rehabilitation plans, which are to be developed with the client during the intake and assessment process. The facility failed to document an individual treatment and rehabilitation plan in client records # 4 and 5. Client # 4 was admitted into treatment on 10/16/14 and was discharged on 4/13/15. The only individual treatment and rehabilitation plan documented in the client's record was dated 2/25/15.Client # 5 was admitted into treatment on 1/22/15 and was discharged on 6/2/15. The only individual treatment and rehabilitation plan documented in the client's record was dated 4/7/15. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff were re-educated on 9/11/15 about individualized treatment plans being retained in client record upon intake and assessment.
Prior to April 2015, the client's electronic record was designed to obtain all documentation from various treatment episodes in one chart. This was changed in April 2015. Each treatment episode per client has its own chart. This resolved errors in medical record system so that accurate prompts to complete documentation resumed.
Each counselor now has an individualized tracking tool that documents completion of treatment plan at intake/assessment. This tool is verified for accuracy by director.
Director will continue to monitor compliance via monthly chart audits. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in two of five client records reviewed.The findings include:Five client records were reviewed for documentation of a complete client record during the renewal inspection on September 10, 2015. The facility failed to document a complete record in client records # 3 and 5. Client # 3 was admitted on 2/12/15 and was successfully discharged on 5/7/15. The facility failed to document follow-up information in the client's record. Client # 5 was admitted on 1/22/15 and was successfully discharged on 6/2/15. The facility failed to documented follow-up information in the client's record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A tracking tool was created for all counselors to document follow up calls. Discharged clients needing called is reviewed weekly at team meeting. The Admin. Assit. verifies that all calls were made each week per the tracking tool. Director is informed of any discrepancies.
The Director will also be monitoring continued compliance by conducting monthly chart audits. |