INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17 -19, 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 31, 2008.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based upon review of fire drill records on December 17, 2007, the facility failed to prepare alternate exit routes to be used during fire drills. Facility documentation indicated that all drills conducted from March 2007 to present were conducted utilizing only the exit stairs by Suite 321.
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Plan of Correction
Program Director will initiate a plan to conduct regular facility fire drills that include the alternating use of stairway exits outside of Suite 321 as well as outside of Suite 305. Compliance will be monitored by written documentation in the fire drill log. |
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 upon review of fire drill records on December 17, 2007, the facility failed to conduct drills at different times of the day. All fire drills conducted from May 2007 through November 2007 were conducted at 1:30 PM and drills conducted during the months of March and April were conducted between 12:45 PM and 1:32 PM.
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Plan of Correction
Program Director will initiate a plan to conduct regular facility fire drills that include fire drills conducted at different times during the day and evening. Director will submit a letter to the Division of Licensing requesting an exemption from sounding the Birmingham Towers system fire alarm after 5:00 PM. Compliance will be monitored by written documentation in the fire drill log. |
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 upon client record review on December 19, 2007, the psychosocial evaluation in one of three client records reviewed was incomplete. The psychosocial evaluation in client record #1 was lacking the page documenting negative factors, the client's attitude toward treatment and the counselor's impressions/conclusions.
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Plan of Correction
Program Director will initiate a training plan for current staff to insure facility policy compliance with the correct completion of the psychosocial evaluation, which includes, but is not limited to, documentation on the negative factors, the client's attitude toward treatment and the counselors impressions/conclusions. The training will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors. |
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 upon review of client records on December 19, 2007, one of three clients did not receive individual sessions twice weekly. Documentation in client record #1 revealed that the client only received one session per week during the weeks of 7/9/07, 7/16/07 & 7/23/07.
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Plan of Correction
Program Director will initiate a training plan for current staff to insure facility policy compliance by providing two individual counseling sessions per week for clients being treated in the PHP level of care.
The training will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors.
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709.82(e)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based upon review of the letters of agreement that were in place on December 17, 2007 and an interview with the staff person represented by employee record #2, the facility lacked documentation to demonstrate that the facility was able to assist clients in obtaining dental support services.
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Plan of Correction
Program Director will initiate contact with a dental health provider with the view to entering into a referral agreement with such provider so that the facility will be able to assist clients in obtaining dental support services. Compliance will be verified by providing a copy of the properly signed and dated referral agreement. |
709.82(e)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based upon review of the letters of agreement that were in place on December 17, 2007 and an interview with the staff person represented by employee record #2, the facility lacked documentation to demonstrate the ability to assist the clients in obtaining legal support services.
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Plan of Correction
Program Director will initiate contact with a legal support services provider with the view of entering into a referral agreement with such provider so that the facility will be able to assist clients in obtaining legal support services. Compliance will be verified by a copy of the properly signed and dated referral agreement. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based upon review of client records on December 19, 2007, two of four client records reviewed lacked signed and/or witnessed consents for treatment. Client record #4 lacked a consent to treatment and client record #5 lacked a signature of the clinician as a witness.
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Plan of Correction
Program Director will initiate a training plan for current staff to insure facility policy compliance by correctly completing client consent for treatment that includes but is not limited to a client signature and a clinician witness to such consents. The training will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors. |
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 upon client records reviewed on December 19, 2007, one of three client records reviewed requiring treatment plan updates lacked an update.
The findings were: Client record # 5 was missing the September 12, 2007 update.
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Plan of Correction
Program Director will initiate a training plan for current staff to insure facility policy compliance with the requirement for completing comprehensive treatment plan updates (every 30 days for PHP and every 60 days for OP). The training will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based upon client records reviewed on December 19, 2007, one of two client records reviewed requiring documentation of current medications, specifically client record #5, lacked documentation to indicate the dose and frequency of use of the medication.
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Plan of Correction
Program Director will initiate a training plan for current staff to insure facility policy compliance with the completion of client medication records which include but are not limited to the dose and the frequency of the use of the medication. The training will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors. |
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 upon client records reviewed on December 19, 2007 the facility failed to provide a complete record of services provided in two of four records reviewed. The records of services in client records #5 & 6 lacked entries for individual treatment sessions.
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Plan of Correction
Program Director will initiate a training plan for current staff to insure facility policy compliance with the completion of the record of service that includes, but is not limited to entries for individual treatment sessions. The training will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based upon client records reviewed on December 19, 2007 two of four client records reviewed were missing progress notes for individual treatment sessions. Client records #5 & 6 were missing some of the progress notes for individual treatment sessions.
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Plan of Correction
Program Director will initiate a training plan for current staff to insure facility policy compliance with the completion of progress notes for each and every individual treatment session provided. The training will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based upon client records reviewed on December 19, 2007 one of two client records lacked a case consultation where case consultations were due. Client record #5 was missing a case consultation.
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Plan of Correction
Program Director will initiate a training plan for current staff to insure facility policy compliance with the completion of the case consult at the required due time. The training will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based upon client records reviewed on December 19, 2007 the facility failed to provide a complete aftercare plan for one of one clients requiring an aftercare plan. Client record #6 lacked goals with time frames and the client portion of the aftercare plan was missing.
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Plan of Correction
Program Director will initiate a training plan for current staff to insure facility policy compliance with the full completion of the client aftercare plan that includes but is not limited to stated goals with time frames and the completed client portion of the aftercare plan. The training will be executed during regularly scheduled clinical staff meetings and individual supervision sessions. Compliance will be monitored by the Program Director during regular monthly chart monitors. |