INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 30, 2012 licensure renewal inspection. The follow-up inspection was conducted on February 14, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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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 two of three client records reviewed.
The findings include:
Three client records and administrative documentation was reviewed on February 14, 2013. There was documentation in the client records #1, and 3 from a Laboratory that provides urinalysis results for random drug testing. The project failed to 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 prior to the exchange of information between the client and the agency providing the urinalysis.
Client #1 was admitted on October 03, 2012 and discharged on January 10, 2013. The facility failed to have the client signed an informed voluntary consent prior to an exchange of information between the facility and the agency providing the urinalysis for each client release information.
Client #3 was admitted on August 24, 2012 and discharged on January 16, 2013. The facility failed to have the client signed an informed voluntary consent prior to an exchange of information between the facility and the agency providing the urinalysis for each client release information.
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Plan of Correction
Since October 8, 2012 all of the Ameritox consents were added to the assessments packets for all new clients to sign versus staff needing to remember to have the client sign. This is reinforced by Facility Director through random chart audits and discussions at staff meetings of any issues with this process. If, at any time, this was missed the therapist is expected to have a conversation with the client and ask for a signature. We also have the contract agreement between Pyramid Healthcare and Ameritox accessible at all times, which is maintained by the Facility Director. |
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.
The findings include:
Three client records were reviewed on February 14, 2013. Three discharge records were required to have documentation of an aftercare plan on #1, 2, and 3. 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 goals with time frames on the aftercare plans for client #1, 2, and 3.
Client #1 was admitted on October 03, 2012 and discharged on January 10, 2013.
Client #2 was admitted on September 24, 2012 and discharged on January 10, 2013.
Client #3 was admitted on August 21, 2012 and discharged on January 16, 2013.
An interview with the facility director confirmed the finding on February 14, 2013.
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Plan of Correction
Facility Director has added a piece to the aftercare form which asks for "time frames" of the action plan. During February 15, 2013 staff meeting it was reiterated the importance of not leaving this blank even if the client is unable to provide a time frame. This will be monitored and reinforced by Facility Director through random chart audits and continuous discussion when needed during weekly staff meeting and clinical supervisions with the clinicians. |