INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 29 - 30, 2012 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.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that counselors met qualifications for the position in one of four records reviewed.
The findings include:
Eight personnel records were reviewed on August 29, 2012. Four of the nine represented the counselors, #3, 4, 5 and 6. An employee hired with a bachelor degree must have a degree from an accredited college in a related field with 1 year of clinical experience.
Employee #6 was hired on November 7, 2011 as an administrative assistant then promoted to counselor assistant on December 26, 2011. Then on August 1, 2011, after her supervision period was over, was promoted to counselor. Employee #6 was hired with no clinical experience and only obtained 8 months of clinical experience after her promotion, to counselor assistant. Employee #6 was required to have a year of clinical experience before promotion to a counselor.
An interview with the facility director on August 29, 2012 confirmed the findings.
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Plan of Correction
Effective August 29th 2012 Counselor Assistant promotion to a full counselor was revoked and a new supervision assessment was completed, which identified that the counselor assistant will be re-assessed for promotion to full counselor at the end of the year of counselor assistant supervision, which is December 22, 2012. To eliminate this from occurring again criteria for what is considered clinical experience will be more clearly defined at agency level by the Facility Director. |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of facility policy and procedures, the facility failed to have documented a policy pertaining to staff development.
The findings include:
The policy and procedure manual was reviewed on August 29 - 30, 2012. The regulation requires a staff development program policy that includes who is responsible and the time frames for completion of the following components: assessment of staff training needs, overall plan for addressing these needs, mechanism to collect feedback on completed training's and an annual evaluation of the overall training plan. During the review of the facility's policy and procedures, the facility did not provide documentation of their staff development program policy. An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
Pyramid Healthcare has an existing policy on addressing staff development. This policy has the following components; coordination, assessment, plan with who is responsible for follow through, feedback, evaluation, and documentation. The policy will be available during site inspections effective immediately. Facility Director will ensure all policies are available at all times. (I do not know how to write this because the policy was in the HR manual) |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
The policy and procedure manual was reviewed on August 29 -30, 2012. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility failed to document the completion of an overall training plan.
An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
Facility Director acquired the overall training plan and filed it in manual to ensure that this document is available during next site visit. Human resources will create this plan and will updated to reflect training plans for the 2013 training year which will be reviewed in 2012. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and CPR certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR.
The findings include:
Nine personnel records and employee CPR certification cards were reviewed on August 29, 2012. Only two employees had current CPR certifications. The facility is open Monday and Thursday 8:30 am to 5:30 pm, Tuesday and Wednesday 8:30 am to 4:30 pm, Friday 8:30 am to 3:30 pm and by appointments in the evening.
No CPR coverage on Wednesday from 4:00 pm to 4:30 pm
No CPR coverage on Friday from 3 pm to 4 pm.
No CPR coverage on Friday from 8:30 am to 9 am
One employee is not sufficient to provide CPR coverage for these hours of operation:
Monday and Wednesday 7:30 am to 9 am
Monday 5:30 pm to 7 pm
Tuesday 7:30 am to 8:30 am
Thursday 7:30 a, to 9:30 am
Tuesday 3 pm to 5:30 pm
Wednesday 3:30 pm to 4 pm
Thursday 3:30 pm to 8 pm
Friday 9 am to 11 am
The facility failed to ensure that a sufficient number of staff persons were trained in CPR.
An interview with the facility director on August 30, 2012, confirmed the findings.
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Plan of Correction
Effective immediately staff schedules with programming was adjusted to ensure that CPR certified staff are onsite. The two staff who have the certification will provide their certification cards by September 21, 2012. Facility Director and at least one other staff will complete CPR and First Aid by October 31, 2012. To ensure that all hours of operation are covered with at least one person CPR certified it will be facility policy that all new staff who are not certified complete the training within the first 6 months of hire date so that all staff will be certified. Facility Director will ensure this happens with all current staff and all new staff. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on the physical plant tour, the facility failed to ensure that the interior exit and stairs are lighted at all times
The findings include:
The physical plant tour took place on August 30, 2012 around 2:30 pm. During the physical plant tour it was observed by this licensing inspector that the room leading to the interior exit door lights was turned off. During the physical plant tour of the second floor, the second exit leading downstairs to the interior exit failed to also have the lights turned on. An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
Effective immediately the interior lights at the back entrance shall remain on during hours of operation. The first staff in the office turns all the appropriate lights on, which includes the back stairway and back room lights. Administrative assistant ensures lights are on when she comes into the office, and Program monitors throughout daily walk throughs.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill records were reviewed on August 29, 2012. The fire drills conducted from February 22, 2012 - July 27, 2012 were reviewed. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility only documented that the front door was used during fire drills for the following months: February 2012, March 2012, April 2012, May 2012 and July 2012. Back door was documented for the month of June 2012.
An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
Facility Director will ensure that the back door is used during the drill in September 2012 and at least once every four months to ensure a variety of exit routes during drills. Only two exits exist, therefore will ensure that the back door is used at least 1 out of every 4 drills. Facility Director will monitor this by reviewing last months' drill log prior to facilitating drill. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation, the facility failed to make available to the public an annual report.
The findings include:
On August 29, 2012, the facility's administrative documentation was reviewed. The facility was required to make an annual report available to the public. The 2011 annual report was provided and reviewed during the inspection; however, the facility failed to verify how the annual report was made available to the public.
An interview with the facility director on August 30, 2012, confirmed the findings.
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Plan of Correction
The annual report is physically mailed regular delivery via the USPS prior to Oct. 1st to recipients on a mailing list that is updated every year by CEO and our marketing representatives. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of the agency policy and procedure manual and administrative reports, the facility failed to document annual goals and objectives which included time frames for the current fiscal year.
The findings included:
Administrative reports were reviewed on August 30, 2012. The annual goals and objectives for 2012-2013 fiscal year, failed to include time frames for completion of those goals and objectives. An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
Effective immediately specific dates will be added to the goals and objectives of Chambersburg Outpatient goals. Facility Director will ensure this occurs in the development of onsite goals and objectives. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of administrative documentation, the facility failed to complete a performance report to summarize progress towards meeting goals and objectives for the fiscal year July 1, 2011 to June 30, 2012.
The findings included:
Administrative documentation was reviewed on August 29 - 30, 2012. The performance report for the summary of goals and objectives for fiscal year July 1, 2011 to June 30, 2012, was requested for review. The report is to be completed at least annually. The performance report summarizing progress towards meeting those goals and objectives was not presented for review. An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
Board meeting minutes will reflect quarterly reviews of goals and objectives and be available for review at next site visit. Board President will ensure that this occurs during Board Meetings. |
709.26(a)(2) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(2) Utilization of volunteers.
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Observations
Based on a review of the facility's policy and procedure manuals, the facility failed to have a policy in place for utilization of volunteers.
The findings include:
The policy and procedure book was reviewed on August 29 - 30, 2012. During the review of the policy and procedure manuals, there was documentation regarding volunteers in several policies throughout the manuals. There was no formal policy in place pertaining to the utilization of volunteers. An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
By 11/1/12 a policy on utilization of volunteers will be in place to address how volunteers are used within the facility. This will be created by the VP of Clinical Services and approved by the Board. The clinical supervision team, board members, and regional directors will ensure that Pyramid has policies to address all regulations. |
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 obtain an informed and voluntary consent in seven of seven client records reviewed.
The findings include:
Seven client records and administrative documentation was reviewed on August 30, 2012. There was documentation in client records # 1, 2, 3, 4, 5, 6, and 7 from a Laboratory that provides urinalysis results for random drug testing. Administrative documentation failed to include a Qualified Service Organization Agreement for the laboratory. Further review of the records showed that the facility failed to obtain an informed voluntary consent prior to the exchange of information between the facility and the agency providing the urinalysis for each client in all records reviewed.
An interview with the facility director on August 30, 2012 did not confirm that they provided information to this agency. However, the company comes to the facility provides services to the client. The agency sends the results to the facility.
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Plan of Correction
Effective immediately all clients will be required to sign a consent for the drug testing laboratory, and if a client chooses not to sign it will be decided by Facility Director if the client can remain in treatment or be referred to another agency. Facility Director will ensure compliance through random chart audits. Also the Qualified Service Agreement was pulled and is available with facility referral agreements. |
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 the client records, the facility failed to document consents to release information which identified the specific information to be disclosed in seven of seven client records.
The findings include:
Seven client records were reviewed on August 30, 2012. The consents to release information forms in records, # 1, 2, 3, 4, 5, 6 and 7 did not indicate what specific information was to be released and to whom the disclosure was being made.
Client #1 was admitted on February 22, 2012. The release of information form signed February 16, 2012 for an emergency contact did not document on the form what specific information was being released. Also, on February 23, 2012 release of information for a government agency did not document on the form specific information being released.
Client #2 was admitted on May 9, 2012. The release of information form signed April 18, 2012 for an emergency contact did not document on the form what specific information was being released.
Client #3 was admitted on May 15, 2012. The release of information forms signed May 15, 2012 for an emergency contact and Doctor. did not document on the forms what specific information was being released.
Client #4 was admitted on April 5, 2012. The release of information form signed March 21, 2012 for an emergency contact did not document on the form what specific information was being released.
Client #5 was admitted on April 15, 2012 and discharged on July 23, 2012. The release of information form signed April 2, 2012 for an emergency contact did not document on the form what specific information was being released.
Client #6 was admitted on April 24, 2012 and discharged on July 26, 2012. The release of information forms signed April 16, 2012 for an emergency contact and Doctor. did not document on the forms what specific information was being released.
Client #7 was admitted on February 23, 2012 and discharged on May 2, 2012. The release of information form signed February 13, 2012 for an emergency contact did not document on the form what specific information was being released.
An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
On August 30, 2012 all staff were instructed and trained on the proper use of and completion of consents, which was again re-instructed September 11, 2012. Also, individual counselors met with clients to update consents, and will continue to do as clients attend treatment. Counselors were instructed to review consents with clients during all individual sessions to ensure what is disclosed is consistent to what the client wants. Facility Director will ensure compliance of this through random chart audits. Follow up documentation training will occur again October 9, 2012. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in seven of seven client records.
The findings include:
Seven client records were reviewed on August 30, 2012. A psychosocial evaluation was reviewed in seven client records, #1, 2, 3, 4, 5, 6 and 7. An interview with the facility director on August 30, 2012 confirmed the findings.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6 and 7 did not include an evaluation of the client's assets/strengths, coping mechanisms, support systems, negative factors towards treatment and the counselor conclusions/impressions of the client.
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Plan of Correction
Staff were trained again on completing clinically based psychosocials on September 11, 2012. Random monthly chart audits conducted by the Facility Director will ensure compliance in meeting this standard. Follow up documentation training will occur again October 9, 2012. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plans in six of seven client records.
The findings include:
Seven client records were reviewed on August 30, 2012. Four client records contained individual treatment and rehabilitation plans which are required to include documentation of the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans contained in client records # 1, 2, 4, 5, 6 and 7 did not include documentation of frequency of treatment and rehabilitation services
Client #1 was admitted to treatment on February 22, 2012. The individual treatment and rehabilitation plan was developed on February 22, 2012. Individual or group sessions were recommended, but the frequency of those sessions was not documented.
Client #2 was admitted to treatment on May 9, 2012. The individual treatment and rehabilitation plan was developed on May 9, 2012. Individual or group sessions were recommended, but the frequency of those sessions was not documented.
Client #4 was admitted to treatment on April 5, 2012. The individual treatment and rehabilitation plan was developed on April 5, 2012. Individual or group sessions were recommended, but the frequency of those sessions was not documented.
Client #5 was admitted to treatment on April 15, 2012. The individual treatment and rehabilitation plan was developed on April 15, 2012. Individual or group sessions were recommended, but the frequency of those sessions was not documented.
Client #6 was admitted to treatment on April 24, 2012. The individual treatment and rehabilitation plan was developed on April 24, 2012. Individual or group sessions were recommended, but the frequency of those sessions was not documented.
Client #7 was admitted to treatment on February 23, 2012. The individual treatment and rehabilitation plan was developed on February 23, 2012. Individual or group sessions were recommended, but the frequency of those sessions was not documented.
An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
On August 30, 2012 and again on September 11, 2012 all clinical staff were instructed to always include recommended frequency of services on the initial and comprehensive plan. Facility Director will ensure compliance of this through random chart audits. Follow up documentation training will occur again October 9, 2012. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document support services on individual treatment and rehabilitation plans in six of seven client records.
The findings include:
Seven outpatient client records were reviewed on August 30, 2012. Seven client records contained individual treatment and rehabilitation plans which are required to include documentation of support services. The individual treatment and rehabilitation plans contained in client records # 1, 2, 4, 5, 6 and 7 did not include documentation of support services
Client #1 was admitted to treatment on February 22, 2012. The individual treatment and rehabilitation plan was developed on February 22, 2012. The individual treatment plan failed to include documentation of support services.
Client #2 was admitted to treatment on May 9, 2012. The individual treatment and rehabilitation plan was developed on May 9, 2012. The individual treatment plan failed to include documentation of support services.
Client #4 was admitted to treatment on April 5, 2012. The individual treatment and rehabilitation plan was developed on April 5, 2012. The individual treatment plan failed to include documentation of support services.
Client #5 was admitted to treatment on April 15, 2012. The individual treatment and rehabilitation plan was developed on April 15, 2012. The individual treatment plan failed to include documentation of support services.
Client #6 was admitted to treatment on April 24, 2012. The individual treatment and rehabilitation plan was developed on April 24, 2012. The individual treatment plan failed to include documentation of support services.
Client #7 was admitted to treatment on February 23, 2012. The individual treatment and rehabilitation plan was developed on February 23, 2012. The individual treatment plan failed to include documentation of support services.
An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
On August 30, 2012 and again on September 11, 2012 all clinical staff were instructed to always include proposed services beyond what the client identifies as supports on the comprehensive plan. Facility Director will ensure compliance of this through random chart audits. Follow up documentation training will occur again October 9, 2012. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to include components in the aftercare plan in three of three discharge records reviewed.
The findings include:
Seven client records were reviewed on August 30, 2012. Three discharge client records were required to have documentation of an aftercare plan, #5, 6 and 7. The following components are required to be documented on the aftercare plan; goals with time frames, support services, contact person and the reentry process. The facility failed to include time frames with the goals and support services on the aftercare plans for client #5, 6 and 7.
Client #5 was admitted on April 15, 2012 and discharged on July 23, 2012.
Client #6 was admitted on April 24, 2012 and discharged on July 26, 2012.
Client #7 was admitted on February 23, 2012 and discharged on May 2, 2012.
An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
Facility Director has added and implemented a section along with action plan to include time frames on all action plans on the aftercare plan. On September 11, 2012 all clinical staff were trained and instructed on ensuring that all recommended support services be included in the aftercare plan beyond what the client says they will follow through with. Facility director will ensure compliance through chart audits on all discharged clients. Follow up documentation training will occur again October 9, 2012. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to include components in the discharge summary.
The findings include:
Seven client records were reviewed on August 30, 2012. Three discharge client records were required to have documentation of a discharge summary, #5, 6 and 7. The following components are required to be documented on the discharge summary; reason for treatment, services offered, respond to treatment and client status. The facility failed to include reason for treatment on the discharge summary for client's #5 and 6. Also, per policy and State standards, discharge summaries are to be completed within 7 days after the clients discharge date.
Client #5 was admitted on April 15, 2012 and discharged on July 23, 2012. The discharge summary was to be completed by July 30, 2012. Client #5's discharge summary was not completed until August 9, 2012, 10 days past the required time.
Client #6 was admitted on April 24, 2012 and discharged on July 26, 2012.
Client #7 was admitted on February 23, 2012 and discharged on May 2, 2012.
An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
On September 11, 2012 all clinical staff were trained and instructed on ensuring that discharge summaries be completed within 7 days of discharge. Also reviewed the content required in each section, which includes appropriate reasons for treatment. Facility director will ensure compliance through chart audits on all discharged clients. Follow up documentation training will occur again October 9, 2012. |