INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 23, 2013 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.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the facility failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports for the 14 facilities contained within the project were reviewed on October 15, 2013. The equivalent of 105.275 full-time counselors are employed within the project. This would require at least 13 full-time clinical supervisors. The project currently employs 7 full-time clinical supervisors.
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Plan of Correction
The Vice President of Clinical Services will ensure that the ration of Clinical Supervisors for the project is within the defined regulation of 1 full time clinical superviosr for every 8 full time counselors or counselor assistants. The Project will re-evaluate its current system & restructure the project to include the appropriate number of clinical supervisors. Human Resources Coordinators will identify the number of clinical supervisors, counselors and counselor assistants within the system on a quarterly basis. Vice President of Clinical Services will be responsible to review staffing hours quarterly to ensure that ratio is maintained. Program Directors will notify the Vice President of Clinical Services should any changes in the ratio per site occur during the quarter. Restructuring of the Clinical SUpervisor ratio will begin December 1, 2013 and Clinical Supervisor ration will be in 100% compliance by January 1, 2014. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one personnel records.
The findings include:
Fourteen personnel records were reviewed on October 8, 2013. One personnel record pertained to the project director required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since July 1, 1999. The facility training year is from July through June. Employee # 1 had documentation of 10.5 hours of training for the July 2012 - June 2013 training year.
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Plan of Correction
Project Manager will complete 12 hours of training annually. Project Manager will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in the Personel File. Human Resources Coordinator will monitor employee files quarterly to ensure 100% compliance |
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 records, the facility failed to document the completion of 25 clock hours of annual training required for clinical staff in one of four personnel records.
The findings include:
Six personnel records were reviewed on October 4, 2013. One personnel record pertained to a counselor required the documentation of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 3.
Employee # 3 has been a counselor since May 1, 2008. The facility training year is from July through June. Employee # 3 had documentation of 22 hours of training for the July 2012 - June 2013 training year.
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Plan of Correction
All clinical Staff will complete 25 hours of training annually. Clinical staff will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in the Personel File. Human Resources Coordinator will monitor employee files quarterly to ensure 100% compliance |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record on October 4, 2013, the facility failed to ensure that fire drills were conducted during different times of the day.
The findings include:
Ten months of fire drills were reviewed. The facility's hours of operation are Monday through Friday 8:30 am -7 pm, Saturday by appointments only. The facility failed to document fire drills during the evening hours after 3 pm to 7 pm and only documented on morning shift drill. The following months were reviewed November 2012-August 2013.
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Plan of Correction
Staff responsible for conducting fire drills and maintaining fire drill logs will be re-trained by the Program Director at the Facility Risk Committee Meeting on 11/22/13. Fire drills will be completed on a minimum of monthly basis to include both day shift and second shift and recorded in the Fire Drill Log. Compliance will be reviewed on at least a monthly basis at the monthly facility meeting of the Risk Committee |
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 on August 22, 2013, the facility failed to provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in nine of ten records reviewed.
The findings include:
The psychosocial evaluations in client records # 6 and 7 did not include an evaluation of the client's problems and needs.
The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 7, 8 and 9 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7, 8 and 9 did not include an evaluation of the client's support systems.
The psychosocial evaluations in client records #1, 2, 5, 6, 7 and 9 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #1, 2, 3, 5, 6, 7, 8 and 9 did not include an evaluation of the negative factors of the client.
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Plan of Correction
Vice President of clinical servcies will retrain clinical staff on the correct completion of the Psychosocial Evaluation including: assets/strengths, coping mechanisms, support systems and negative impacts of use. Program Director will monitor correct completion of Psychosocial Evaluations monthly in Open Chart Monitors. Evaluations will be monitored until 90% compliance is achieved for 3 consecutive months. All Chart Monitors will be reviewed by Vice President of Clinical Services |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records on October 23, 2013, the facility failed to complete sixty day treatment plan updates in four of ten client records.
The findings include:
Sixty day treatment plan updates were required in five client records, #1, 2, 3, 4, 5, 6 and 9. The facility did not document treatment plan updates every sixty days in client records # 1, 2, 5 and 6.
Client # 1 was admitted on July 19, 2013 and the comprehensive treatment plan was completed on July 30, 2013. A treatment plan update was due by September 30, 2013. Treatment plan update was completed on October 1, 2013.
Client # 2 was admitted on July 15, 2013 and the comprehensive treatment plan was completed on July 15, 2013. A treatment plan update was due by September 15, 2013. Treatment plan update was completed as of the date of the licensing inspection.
Client # 5 was admitted on July 11, 2013 and the comprehensive treatment plan was completed on July 16, 2013. A treatment plan update was due by September 16, 2013. Treatment plan update was completed on October 3, 2013.
Client # 6 was admitted on July 29, 2013 and the comprehensive treatment plan was completed on July 29, 2013. A treatment plan update was due by September 29, 2013. Treatment plan update was completed as of the date of the licensing inspection.
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Plan of Correction
Program Director will retrain all clinical staff in the proper completion of all treatment forms and documentation including timelines at the clinical staff meeting on 11/8/2013. Clinical documentation will be reviewed by the Program Director monthly for existing staff and weekly for all probationary staff.Clinical Documntation review will be documented in the Open and Closed Chart Monitors. Monitors will be reviewed by the Vice President of Clinical Services. |
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 a review of client records on October 23, 2013, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project in six of ten records reviewed.
The findings include:
Client #5 was admitted on July 11,2013. The case consultation was due by October 11, 2013. As of the date of the licensing inspection client #5 failed to have documentation of a case consultation.
Client #6 was admitted on July 29, 2013. The discharge summary documented on September 25, 2013 failed to include the services offered to the client and the client's status at discharge.
Client #7 was admitted on August 13, 2013. The discharge summary documented on September 20, 2013 failed to include the clients reason for treatment and the client's status at discharge.
Client #8 was admitted on August 12, 2013 and discharged on October 7, 2013. The facility failed to document a follow-up as of the date of the licensing inspection.
Client #9 was admitted on June 13, 2013 and discharged on October 2, 2013. The facility failed to document a follow-up as of the date of the licensing inspection.
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Plan of Correction
Program Director will retrain all clinical staff in the proper completion of all treatment forms and documentation including timelines at the clinical staff meeting on 11/8/2013. Clinical documentation will be reviewed by the Program Director monthly for existing staff and weekly for all probationary staff.Clinical Documentation review will be documented in the Open and Closed Chart Monitors. Monitors will be reviewed by the Vice President of Clinical Services |