INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 30, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, 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 investigation and a plan of correction is due on August 31, 2009.
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Plan of Correction
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704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on a review of the ratio for Partial Hospitalization activities, the facility failed to maintain a ratio of 10/1 for four of the thirteen weeks reviewed.
The findings include:
The past thirteen weeks of partial hospitalization services were reviewed on 8-10-09. The weeks reviewed included 3-30-09, 4-6-09, 4-13-09, 4-20-09, 4-27-09, 5-4-09, 5-11-09, 5-18-09, 5-25-09, 6-1-09, 6-8-09, 6-15-09 and 6-22-09. Ratios of 10/1 are required in all 13 weeks. The facility failed to maintain a 10/1 ratio in four of the weeks. The ratio for the week of 5-25-09 was 15/1. The ratio for the week of 6-1-09 was 17/1. The ratio for the week of 6-8-09 was 14/1. The ratio for the week of 6-22-09 was 13/1.
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Plan of Correction
Program Director has hired an additional partial hospitalization counselor to maintain a client to staff ratio of 1:10. This was done on Monday, August 10, 2009. Program Director will instruct all staff to check client to staff ratios (must be no more than 1:10) before scheduling an admission to the partial hospitalization program. This will be monitored weekly at staff meetings. Current ratios are in compliance. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the caseloads for Outpatient activities, the facility failed to maintain a caseload of 35/1 for one of the thirteen weeks reviewed.
The findings include:
The past thirteen weeks of outpatient services were reviewed on 8-10-09. The weeks reviewed included 3-30-09, 4-6-09, 4-13-09, 4-20-09, 4-27-09, 5-4-09, 5-11-09, 5-18-09, 5-25-09, 6-1-09, 6-8-09, 6-15-09 and 6-22-09. Caseloads of 35/1 were required for all 13 weeks. The facility failed to maintain caseloads of 35/1 or less in one of the weeks. The caseload for the week of 4-13-09 was 38/1.
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Plan of Correction
Program Director will instruct all staff to check client to staff ratios (must be no more than 1:35) before scheduling an admission to the outpatient or intensive outpatient programs. This will be monitored weekly at staff meetings. Current ratios are in compliance. |
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, the facility failed to document a psychosocial evaluation in three of five client records.
The findings include:
Seven client records were reviewed on 7-30-09 during a complaint investigation. Five client records were required to have documentation of a psychosocial evaluation. Three of the five client records presented did not include documentation of a psychosocial evaluation.
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Plan of Correction
Program Director will instruct counseling staff to complete a psychosocial evaluation on all clients by the 5th session of attendance. Program Director will train staff on how to complete this document on August 24 & 25, 2009. Program Director will also instruct staff to complete a psychosocial evaluation on all current clients who have attended more than 5 sessions and do not yet have one. Compliance will be monitored by monthly chart monitors and random chart monitors (completed by Lead Counselor and/or Program Director). Compliance will be by October 1, 2009. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on staff interviews and the review of patient records, the clients are not receiving the two individual sessions required in by the Partial Hospitalization activity level.
The findings include:
Seven client records were reviewed on 7-30-09. Five client records were required to have documentation of two individual counseling sessions per week. Five of the client records reviewed did not include documentation of any services provided. Documentation of progress notes and records of service is missing.
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Plan of Correction
Program Director will instruct partial hospitalization staff to offer all clients two individual sessions per week and document attendance on the record of service and in a progress note in DAP format. Compliance will be monitored by monthly and random chart monitors (completed by Lead Counselor and/or Program Director). Compliance will be by October 1, 2009 |
709.83(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record which includes information relative to the client's involvement with the project in four of five client records.
The findings include:
Seven client records were reviewed on 7-30-09. Five client records are required to have documentation of complete information relative to the client's involvement with the project.
Four of the five client records presented did not include documentation of services.
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Plan of Correction
Program Director will instruct counseling staff to keep a complete client record on all clients. Program Director will train staff on this process/documentation requirements on August 24 & 25, 2009. Compliance will be monitored by monthly and random chart monitors (completed by Lead Counselor and/or Program Director). Compliance will be by October 1, 2009. |
709.83(a)(8) 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:
(8) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of service in four of five client records.
The findings include:
Seven client records were reviewed on 7-30-09. Five records were required to have documentation of a record of service. Four of the five client records presented did not include a record of service.
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Plan of Correction
Program Director will instruct counseling staff to complete a record of service on all clients. Program Director will train staff on how to complete a record of service on August 24 & 25, 2009. Compliance will be monitored by monthly and random chart monitors (completed by Lead Counselor and/or Program Director). Compliance will be by October 1, 2009. |
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 of client records, the facility failed to document progress notes in four of five client records.
The findings include:
Seven client records were reviewed on 7-30-09. Five client records were required to have documentation of progress notes. Four of the five client records presented did not include progress notes.
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Plan of Correction
Program Director will instruct counseling staff to complete progress notes on all clients. Program Director will train staff on how/when to complete progress notes on August 24 & 25, 2009. Compliance will be monitored by monthly and random chart monitors (completed by Lead Counselor and/or Program Director). Compliance will be by October 1, 2009. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation of the space occupied by the licensing specialists during the complaint investigation, the facility failed to secure client records within a locked storage container.
The findings include:
The licensing specialists occupied the Utilization Supervisor's office to conduct the compliant investigation on July 30, 2009. Under the desk, were located twenty four client records. The records were not secured in a locked container, but were stacked on the floor. When the Director of Outpatient Services and the Program Director were questioned, they were unaware that the client records had been stored there and did not know why they were there.
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Plan of Correction
Program Director will instruct all staff to secure client charts in a locked file cabinet, behind a locked door. Compliance will be monitored weekly by Program Director, Assessment Supervisor, and Lead Counselor. Compliance will be by October 1, 2009.
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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 client record review , the facility failed to document an informed consent to release information from the client prior to the disclosure of information in four of seven client records.
The findings include:
Seven client records were reviewed during the complaint investigation on 7-30-09.
Two of the client records reviewed did not include a signed consent to release information form, however, the two client records contained documentation demonstrating that information was disclosed. One disclosure of information was a letter dated 7-24-09 that was sent to a judge, and one disclosure was a telephone call to hospital on 7-7-09.
Two of the seven records did not address all components on the release of information form. One record included a release of information form for a physician that did not list the specific information to be disclosed. One record included a release of information form for drug court and one release of information form for an emergency contact; neither indicated the specific information to be disclosed.
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Plan of Correction
Program Director will instruct staff to obtain a release of information prior to sharing client information. Program Director will instruct staff to properly complete the release of information. Program Director will train staff on this documentation on August 24 & 25, 2009. Compliance will be monitored by monthly and random chart monitors (completed by Lead Counselor and/or Program Director). Compliance will be by October 1, 2009. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based on the review of the incident report, and the staff interviews, the facility failed to have a qualified staff member administer medication, specifically Buprenorphine, to the patient.
The findings include:
The staff interviews conducted on 7-30-09, and the review of the incident report on 7-30-09 confirmed that the facility did not have a qualified staff member administer medication, specifically Buprenorphine, to the patient. The director who is not a physician, physician assistant, registered nurse or Licensed practical nurse administered the medication to a client on 7-1-09.
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Plan of Correction
Program Director will instruct all staff who work with the Suboxone program that only a physician, physician assistant, registered nurse, or licensed practical nurse can administer medication. Compliance will be monitored by weekly review of the medication administration record (done by the licensed practical nurse assigned to the program). Compliance is current. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of client records, the facility failed to document a completed Buprenorphine Administration Record in four of four client records.
The findings include:
Seven records were reviewed on July 30, 2009. A Buprenorphine Administration Record was required in four client records. All four records did not include a signature or an initial of the staff member who administered the medication, Suboxone.
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Plan of Correction
Program Director will instruct all staff administering suboxone to initial or sign a medication administration record. Compliance will be monitored by weekly review of the medication administration record (done by the licensed practical nurse assigned to the program). Compliance is current. |
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, the facility failed to document a psychosocial evaluation in two of two client records.
The findings include:
Seven client records were reviewed on 7-30-09. Two client records were required to have documentation of a psychosocial evaluation. Two of the two client records presented did not include documentation of a psychosocial evaluation.
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Plan of Correction
Program Director will instruct counseling staff to complete a psychosocial evaluation on all clients by the 5th session of attendance. Program Director will train staff on how to complete this document on August 24 & 25, 2009. Program Director will also instruct staff to complete a psychosocial evaluation on all current clients who have attended more than 5 sessions and do not yet have one. Compliance will be monitored by monthly chart monitors and random chart monitors (completed by Lead Counselor and/or Program Director). Compliance will be by October 1, 2009. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of services in two of two client records.
The findings include:
Seven client records were reviewed on 7-30-09. Two client records were required to have documentation of a record of services. Two of the two client records presented did not include documentation of a record of services.
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Plan of Correction
Program Director will instruct counseling staff to complete a record of service on all clients. Program Director will train staff on how to complete a record of service on August 24 & 25, 2009. Compliance will be monitored by monthly and random chart monitors (completed by Lead Counselor and/or Program Director). Compliance will be by October 1, 2009. |