INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15-16, 2011 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:
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all heaters were permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on November 15, 2011 from 3:15 PM to 4:00 PM. During the tour at around 3:45 PM, a portable space heater was detected on the second floor counselor's office.
The facility director and maintenance director were present and verified the findings.
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Plan of Correction
Program Director will meet with facility maintenance man by 12/7/11 in order to review the importance of ensuring that all heaters are permanently mounted or installed. Program Director will then monitor adherence to the policy via monthly walk throughs of the physical plant with the facility's maintenance man. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records and the facility's policies and procedures manual, the facility failed to document a follow-up attempt in accordance with the facility's policies and procedures in two of three client records.
The findings include:
In reference to follow-ups the facility's policy states:
If a client has an aftercare appointment in place: within 7 days of the initial appointment a designated staff member will contact the client to verify that the initial aftercare appointment was kept.
If a client has no specific aftercare appointment but has been given specific instructions on how to continue progress made in treatment: within 7 days of discharge a designated staff member will contact the client to verify that client is following aftercare recommendations.
On November 16, 2011 three client records were reviewed for documentation of a follow up. Two of the client records reviewed lacked follow-up documentation specifically records # 4 and 5.
Client #4 was admitted on July 21, 2011 and discharged on October 23, 2011 without an aftercare appointment. A follow-up attempt was due by October 30, 2011, instead a follow-up attempt was documented on November 8, 2011.
Client #5 was admitted on July 11, 2011 and discharged on October 7, 2011. An aftercare appointment was made for October 10, 2011. A follow up attempt was due by October 17, 2011, instead a follow-up attempt was documented on October 24, 2011.
The findings were confirmed by the facility director.
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Plan of Correction
Program Director will meet with the Administrative Assistant (as this individual completes this particular phone call) by 12/9/11 to review the policy on aftercare follow ups and adherence to doing so within 7 days of discharge if no specific appointment was scheduled or within 7 days of a scheduled appointment. Program Director will then monitor adherence to this policy via monthly closed chart monitors. |