INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17- 18, 2007 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 January 25, 2007.
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Plan of Correction
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709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of two client records on December 17- 18, 2007, the facility failed to document a completed drug and alcohol history. A review of two client records, specifically #1 and 2, revealed that the drug and alcohol history failed to address current and previous alcohol and/or drugs used by the client , lengths and patterns related to the progressions of use and the client's perception of use.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. 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 client records on December 17- 18, 2007, the facility failed to document completed personal histories. A review of two client records, specifically #1 and 2, revealed that employment/vocation, recreation and sexual data within the personal history had unanswered questions. In addition, various documentation in client record #1 was illegible.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.81(b)(6) LICENSURE Intake and admission
709.81. 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 on December 17- 18, 2007, the facility failed to legibly document a psychosocial evaluation based on the clinician's analysis of the collected historical information. A review of one of two client records, specifically #1, revealed that the psychosocial evaluation was illegible and therefore could not be adequately reviewed for completeness.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 two client records on December 17- 18, 2007, the facility failed to document the type and frequency of services on the individual treatment and rehabilitation plan. A review of client records #1 and 2 revealed that the frequency for the type of treatment service provided was not documented on the individual treatment and rehabilitation plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of two client records on December 17- 18, 2007, the facility failed to document a treatment plan update that included the client's progress as it relates to the goals identified on the individual treatment plan. A review of client record #1 revealed that the treatment plan update was illegible; therefore, compliance with the regulation could not be determined. In client record #2 the treatment plan update due on June 20, 2007 was missing.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.83(a)(9) LICENSURE Client records
709.83. 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) Progress notes.
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Observations
Based on a review client records on December 17- 18, 2007, the facility failed to document progress notes based on data, assessment and plan as indicated in the project's policy manual. A review of two of two client records, specifically #1 and 2, revealed that progress notes did not include the clinician's assessment or plan for the client. In addition, the progress notes had no continuity in relation to the individual treatment plan. The majority of the progress notes in client record #1 were illegible and compliance with the regulation could not be determined.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records on December 17- 18, 2007, the facility failed to document a completed drug and alcohol history. A review of the four client records, specifically #1, 2, 3 and 4, revealed that documentation in the drug and alcohol history failed to include the lengths and patterns related to the client's drug and alcohol use as well as the client's perception of use.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of four client records on December 17- 18, 2007, the facility failed to provide psychosocial evaluations that included the clinician's opinions regarding the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may effect treatment, client's attitude toward treatment and overall conclusions/impressions. A review of client records #1, 2, 3 and 4 revealed that the psychosocial evaluations were primarily historical containing the clients' comments rather than clinically evaluative statements from the clinician. In addition, the areas of client's assets/strengths, support systems and negative factors that may impact treatment and recovery consisted only of comments with no further explanation or clarification.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 on December 17- 18, 2007, the facility failed to document the type and frequency of services on the individual treatment and rehabilitation plan. A review of four of four client records, specifically #1, 2, 3 and 4, revealed that the frequency for the type of treatment service provided was not documented on the individual treatment and rehabilitation plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records on December 17- 18, 2007, the facility failed to integrate work therapy as a goal in the treatment and rehabilitation plan. A review of two of three client records, specifically #3 and 4, revealed that the documentation failed to demonstrate that work completed by the client was an integral part of the client's treatment and rehabilitation plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |