INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 28-29, 2008 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 November 24, 2008.
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Plan of Correction
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on the review of four personnel records, one was reviewed as a counselor assistant. The facility failed to provided supervision by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 in one of one personnel record where required.
Findings:
The counselor assistant's supervision was provided by the facility director as documented by the signature of the facility director on the supervision notes.
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Plan of Correction
The Program Director will assign a full time counselor who meets the qualifications in 704.6 or 704.7 to provide supervision to the counselor assistant. This will be in compliance on 12/1/2008 and compliance will be indicated by the signature of the assigned counselor who will provide supervision on the supervision notes. This will be monitored by the Program Director through regular review of the supervision notes. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of thirteen client records on October 29, 2008, the facility failed to develop an individual treatment and rehabilitation plan in five of six client records where required.
Findings:
The short and long terns goals were identical, thus not individualized, in client records # 1, 2, 4, 5 and 6. There were no individual goals noted on the treatment plans.
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Plan of Correction
Program Director will initiate a training plan for all clinical staff on 11/24/2008 to address that short and long term goals should not be identical and thus should be individualized. Additionally this training plan will address that individual goal notes are to be documented on the treatment plans. This will be in compliance on or before 12/31/2008 and will be indicated on training minutes. Compliance will be monitored through regular monthly chart monitors by the Program Director. |
709.82(a)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on the review of thirteen client records on October 29, 2008, the facility failed to develop individualized short- and long-term goals for treatment in five of six client records where required.
Findings:
The short and long terns goals were identical, thus not individualized, in client records # 1, 2, 4, 5 and 6.
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Plan of Correction
Program Director will initiate a training plan for all clinical staff on 11/24/2008 to address that short and long term goals should not be identical and thus should be individualized. This will be in compliance on or before 12/31/2008 and will be indicated on training minutes. Compliance will be monitored through regular monthly chart monitors by the Program Director. |
709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on the review of thirteen client records on October 28-29, 2008, the facility failed to inform the client of the right to appeal a decision limiting access to his records to the project director in thirteen of thirteen client records where required.
Findings:
There was no documentation that the client was informed of this right in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13.
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Plan of Correction
The Director of Outpatient Services by 11/3/2008 will amend the current consent for treatment that will include a statement that informs the client of the right to appeal a decision limiting access to his records to the project director. This will be in compliance on or before 12/12/2008. Compliance will be indicated by the properly completed consent for treatment with proper signature of client and witness and date. Compliance will be monitored through monthly chart monitors by the Program Director. |
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 the review of thirteen client records on October 28-29, 2008, the facility failed to develop a psychosocial evaluation that included the counselor's clinical conclusions and impressions in four of seven client records where required.
Findings:
The impressions and conclusions in client records # 8, 9, 10 and 13 were either historical in nature or client reported information. The psychosocial evaluations in those client records did not include the counselor's evaluations.
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Plan of Correction
The Program Director will initiate training for all clinical staff on 11/24/2008 that will address the need for counselors to indicate their clinical conclusions and impressions that are not historical in nature or client reported. This will be in compliance on or before 12/31/2008 and will be indicated on training minutes. Compliance will be monitored through regular monthly chart monitors by the Program Director. |
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 on the review of thirteen client records on October 29, 2008, the facility failed to document a complete aftercare plan in two of two client records where required.
Findings:
The aftercare plan in client records #11 and 13 were missing support services and the contact person. In client record # 13, there were no time frames listed for the goals.
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Plan of Correction
The Program Director will initiate a training plan on 11/24/2008 that will address the proper completion of the aftercare plan that indicates support services and the contact person as well as listing time frames for the goals. This will be in compliance by 12/31/2008 and will be indicated on training minutes. Compliance will be monitored through regular monthly chart monitors by the Program Director. Program Director will complete a change of forms request to the forms committee by 12/4/08. This request will be to add a line for a counselor contact person. Once the new form is approved by the forms committee, the Program Director will provide all clinical staff with the updated version of the aftercare plan. Compliance in using this new form will be monitored through regular monthly chart monitors by the Program Director. |