INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on March 6 through 7, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on April 9, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback was not documented for outside training in all employee records reviewed.
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Plan of Correction
HR Assistant sent notice via email to all Program Directors and Supervisors in early March 2007, informing of the regulation/policy requiring the collection of feedback on all completed trainings. The HR Department is ensuring compliance with this standard by monitoring all submitted training certificates, and not issuing credit for the training until the evaluation is completed and submitted to Human Resources. HR Director is responsible for the overall organizational compliance with this standard. Target date for completion was March 15, 2007.
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The policy and procedure manual at the main administrative office and the manuals at the facilities were not consistent with regard to policies and procedures. The organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures.
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Plan of Correction
The Master Policy Manual will be reviewed by Policy Coordinator, and the Chief Operating Officers from each division (Adult Residential, Adolescent Residential and Outpatient). The purpose of this review is to 1) ensure consistency of policies across the organization, and 2) to re-organize the Master manual, separating out Drug and Alcohol Program policies from DPW-licensed Program policies, ensuring ease of access to the policies, and diminishing the potential for misunderstanding of the intent of the policies/procedures. Policy Coordinator will be responsible for ensuring that the Table of Contents accurately reflect the content of the manual. CEO/Project Director will be responsible for ensuring timely completion of this project. Target date for final completion of this project is June 1, 2007.
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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
The HIPAA Notice of Privacy Practices form contains incorrect information in sections III L. and O.; IV. F; V. A and C.; VI E and H and VII.
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Plan of Correction
The Notices of Privacy Practices document was revised on April 4, 2007 by Medical Records Corporate Coordinator, as per recommendations by Department of Health staff during the licensing visit. The COO - Adult Residential Services, will submit the revised document to the Department of Health for review and approval by April 13, 2007. Once approved by the State, targeted implementation is April 20, 2007.
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709.53(a)(5) LICENSURE Progress Notes
709.53. 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
Group progress notes do not address which treatment plan goal is being addressed. This is to be done per Pyramid policy.
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Plan of Correction
Policy Coordinator for Pyramid Healthcare was contacted in reference to the policy regarding progress notes. Policy Coordinator will review policy and modify it accordingly. Clarification of the definition of progress notes and what is required within them will be determined. The current policy will be changed by the Policy Coordinator to reflect categories of progress notes. Categories will be divided into individual treatment progress notes that require an identifier of treatment goals being addressed and generalized progress notes that will not require recognition of individual treatment goals. The later of the two categories will include general daily progress notes, group therapy notes, as well as any progress notes completed dealing with psycho-educational groups and family therapy. Revisions will be completed by the Policy Coordinator be May 15, 2007 and distributed to Program Directors. Program Directors will be responsible for implementing all changes by no longer than June 1, 2007. Implementation will include replacing the existing policy with the revised policy as well as training for all clinical staff orienting them to the new procedure. Program Director will review charts weekly for a period of 60 days to ensure progress notes are completed properly according to policy revision.
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