This report is a result of an on-site licensure renewal inspection conducted on July 11-12, 2024, 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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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven applicable records reviewed.Client #3 was admitted on March 28, 2024, and was still active at the time of the inspection. The comprehensive treatment plan dated April 18, 2024, indicated one individual session twice a month and three group sessions a week. For the month of May only one individual session was documented on May 2, 2024. Additionally, for the period of June 1-June 27, 2024, only one group session was documented on June 11, 2024. Client #4 was admitted on April 29, 2024, and discharged on June 25, 2024. A comprehensive treatment plan dated May 16, 2024, indicated weekly group sessions. There was no documentation that the client received a group session between May 16-May 30, 2024. Client #7 was admitted January 29, 2024, and was discharged April 23, 2024. A comprehensive treatment plan dated February 20, 2024, indicated two individual sessions per month. During the month of March 2024 only one individual session was documented on March 28, 2024. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On August 26th, 2024, Clinical Supervisor will conduct a group supervision on how to engage the clients to attend the treatment according to the treatment plan collaboratively developed between the counselor and client. The clinical staff will also review client barriers to treatment to prevent a lack of engagement due to life circumstances and discuss how to support the barriers to treatment or provide a solution if possible. Clinical Staff will be advised that every client should be leaving an individual session with an upcoming appointment and placed on a group roster.
On August 19th, 2024 in the weekly staff meeting, the Executive Director and Clinical Supervisor will review with the Clinical staff on the importance of making more frequent outreach calls, correspondence letters, emails to encourage engagement and what documentation will be utilized to document the outreach as completed.
Starting on August 19th, group rosters and caseload reports will be reviewed to ensure that every client is enrolled on a group roster and will be reviewed in the weekly staff meeting going forward.
A monthly chart audit and a meeting with the Regional Quality Manager, Executive Director, and Clinical Supervisor will be completed to ensure that the frequency of treatment requirements are in accordance with state and county funder expectations.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy is that case consultations must be completed within ninety-days of admission. Client #3 was admitted on March 28, 2024, and was still active at the time of the inspection. There was no documentation of a completed case consultation in the client record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning on August 12th, 2024 the staff will complete case consults in the weekly staff meeting to avoid any overdue case consultations. Each Clinical team member will bring the case load tracker results with them along with the computer to complete the case consultation while in the staff meeting.
Beginning on July 29th, the Clinical Supervisor will provide an updated copy of each clinical team member's caseload on Monday of each week to bring to the staff meeting. The Clinical Team will return the caseload trackers completed by Friday of every week and the Clinical Supervisor will review the returned caseload trackers for completion of documentation.
A case consultation will be completed in the PYR SA transition bundle every time a client is transitioning to a new level of care. A case consultation will be completed every time a client is being discharged in the PYR SA discharge bundle.
A monthly chart audit and a meeting with the Regional Quality Manager, Executive Director, and Clinical Supervisor will be completed to ensure that the frequency of treatment requirements and documentation is being met in accordance with state and county funder expectations. |