INITIAL COMMENTS
|
This report is a result of a complaint investigation conducted on April 23, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Pyramid Healthcare Inc., Erie Outpatient were substantiated. A plan of correction must be submitted by May 22, 2010.
|
Plan of Correction
|
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a psychosocial evaluation in three of four partial hospitalization client records.
The findings include:
Sixteen client records were reviewed on April 23, 2010. Four of those client records reviewed were partial hospitalization clients and all were required to have a psychosocial evaluation. Per the facility policy, psychosocial evaluations are required to be completed within 5 sessions after admission. The facility failed to document a psychosocial evaluation in client records # 1, 2 and 4.
In client record # 1, the client was admitted on April 9, 2010. The psychosocial evaluation was due by April 15, 2010 and was not completed. The facility failed to document the completion of a psychosocial evaluation.
In client record # 2, the client was admitted on April 9, 2010. The psychosocial evaluation was due by April 15, 2010 and was not completed. The facility failed to document the completion of a psychosocial evaluation.
In client record # 4, the client was admitted on March 24, 2010. The psychosocial evaluation was due by April 1, 2010 and was not completed. The facility failed to document the completion of a psychosocial evaluation.
An interview with the facility director took place on April 23, 2010 at which time it was confirmed that there were no psychosocial evaluations in the aforementioned client records.
|
Plan of Correction
Program Director scheduled a training for all clinical staff members. The training will review the timeline stating that psychosocial's need completed by the 5th session. This training will also review the criteria that is required to be in the psychosocial's. The Program Director will also monitor compliance through monthly open and closed chart monitors. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a psychosocial evaluation in two of five outpatient client records.
The findings include:
Sixteen client records were reviewed on April 23, 2010. Twelve of those client records reviewed were outpatient clients and five were required to have a psychosocial evaluation. Per the facility policy, psychosocial evaluations are required to be completed within 5 sessions after admission. The facility failed to document a psychosocial evaluation in client records # 7 and 8.
In client record # 7, the client was admitted on April 6, 2010. The psychosocial evaluation was due by April 14, 2010 and was not completed. The facility failed to document the completion of a psychosocial evaluation.
In client record # 8, the client was admitted on March 4, 2010. The psychosocial evaluation was due by April 1, 2010 and was not completed. The facility failed to document the completion of a psychosocial evaluation.
An interview with the facility director took place on April 23, 2010 at which time it was confirmed that there were no psychosocial evaluations in the aforementioned client records.
|
Plan of Correction
Program Director scheduled a training for all clinical staff members. The training will review the timeline stating that psychosocial's need completed by the 5th session. This training will also review the criteria that is required to be in the psychosocial's. The Program Director will also monitor compliance through monthly open and closed chart monitors. |