INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed inlcude that clients may not be discriminated against based on sex, ethnicity and martial status.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In response to the citation concerning 709.30, Client Rights, the project shall develop written policies and procedures on clients rights and document written acknowledgement by client they have been notified of those rights; it was noted that the facilities policy and procedure manual did not list that clients may not be discriminated against based on sex, ethnicity, and marital status however the client handbook did list these items.
Compliance department was notified of this discrepancy by Executive Director on 6/6/2023. At that time Compliance made the appropriate changes to the policy and procedure manual to include these missing items and updated policy was submitted to licensing agency on 6/6/2023. This policy was approved by licensing agency at that time and Executive Director was made aware of approval by licensing agency on 6/7/2023.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on three of seven applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records #3, #4 and #7.
Client # 3 was admitted on September 28, 2022, and was still active at the time of the inspection. A treatment and rehabilitation plan update was developed on November 18, 2022. A treatment and rehabilitation plan update was due no later than January 18, 2023. There was no documentation of a treatment plan update in the client record until May 11, 2023.
Client # 4 was admitted on August 15, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan update was developed on March 2, 2023. A treatment and rehabilitation plan update was due no later than May 2, 2023. There was no documentation of a treatment plan update in the client record.
Client #7 was admitted on May 30, 2022 and was discharged on March 22, 2023. A treatment plan and rehabilitation plan update was developed on October 6, 2022. A treatment and rehabilitation plan update was due no later than December 6, 2022. There was no documentation of a treatment plan update in the client record until December 29, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to the citation concerning 709.92, Treatment and rehabilitation service, treatment and rehabilitation plans shall be reviewed and updated every 60 days; all clinical staff were educated on June 12, 2023 about treatment plan requirements during weekly staff meeting by Clinical Supervisor and Executive Director. In an effort to improve this deficiency in the future, Clinical Supervisor and Executive Director will be updating the case tracker with the following information:
- Treatment plan update column will be dated 45 days from last treatment plan update. This will ensure a treatment plan is updated within the 60 day review period per 709.92b. This will also provide the clinical staff a short window of time to reschedule the client, should they cancel and/or no show their scheduled treatment plan session, without treatment plan becoming delinquent.
- A column will also be added to the case tracker indicating when the next individual session is scheduled for the client to ensure clients are scheduled for their individual session within the 60 day review period for the treatment plan.
Changes to the case tracker were made by Clinical Supervisor on 6/19/2023 and plan of correction has been implemented. Clinical Supervisor will ensure case tracker is updated weekly and clinical staff were educated to review the case tracker at the beginning of each shift to ensure treatment plans are completed timely and individual sessions have been scheduled for all clients on their caseload. Furthermore, in another effort to assist the clinicians, the Clinical supervisor has begun putting notes on the clinicians' scheduled appointments indicating if treatment plan is needed.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of seven client records, the facility failed to document and complete follow up information in one of three applicable client records.
Client #5 was admitted on October 28, 2022 and was discharged on January 22, 2023. There was no documentation of follow up information being completed in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to citation concerning 709.93, Client Records, there shall be a complete client record on an individual which includes information related to client's involvement with the project including but not limited to follow up information; all clinical staff were educated on June 12, 2023 about follow up discharge call completion. Staff were informed the call must be completed within 7 days of completion of the discharge management plan.
In effort to improve this deficiency, Executive Director and Clinical supervisor will review with compliance department to request the discharge follow up call a required document within in the discharge bundle of the electronic medical record. Making this a required document within the discharge management bundle created would not allow the clinician to fully sign the discharge documentation without this form. This will be discussed during monthly call with compliance on 6/27/2023.
Until this documentation request is reviewed and discussed with compliance team, Clinical Supervisor and Executive Director have implemented the following plan on 6/19/2023:
- Clinical staff will route discharge management plan and treatment summary to Clinical Supervisor for review. Upon review of these documents, clinical supervisor will review if discharge follow up call documentation was completed. If not completed, Clinical Supervisor will not sign off on documentation until call is completed. Clinical Supervisor will notify clinical staff of incomplete documentation and inform clinical staff to notify supervisor when complete.
- Once all documentation is completed, Clinical Supervisor will review chart, complete signature of documentation, and close client record in electronic medical record.
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