Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in fourteen out of fourteen client records reviewed.
Client #1 was admitted to the outpatient level of care on November 21, 2024 and was active at time of inspection. There was no documentation that a copy of the informed and voluntary consent to release information form for a funding source dated November 20, 2024, was offered to the client.
Client #2 was admitted to the outpatient level of care on October 08, 2024 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated October 08, 2024, was offered to the client.
Client #3 was admitted to the outpatient level of care on March 14, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated March 14, 2025, was offered to the client.
Client #4 was admitted to the outpatient level of care on December 02, 2024 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated December 03, 2024, was offered to the client.
Client #5 was admitted to the outpatient level of care on October 11, 2024 and discharged on May 12, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated October 12, 2024, was offered to the client.
Client #6 was admitted to the outpatient level of care on October 22, 2024 and discharged on April 29, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated October 22, 2024, was offered to the client.
Client #7 was admitted to the outpatient level of care on September 24, 2024 and discharged on March 18, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated September 24, 2024, was offered to the client.
Client #8 was admitted to the partial hospitalization level of care on January 06, 2025 and was discharged on March 04, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated December 12, 2024, was offered to the client.
Client #9 was admitted to the partial hospitalization level of care on September 27, 2024 and discharged on November 22, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated September 20, 2024, was offered to the client.
Client #10 was admitted to the partial hospitalization level of care on April 29, 2025 and discharged on June 26, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated April 28, 2025, was offered to the client.
Client #11 was admitted to the partial hospitalization level of care on May 21, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated May 21, 2025, was offered to the client.
Client #12 was admitted to the partial hospitalization level of care on May 28, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated May 28, 2025, was offered to the client.
Client #13 was admitted to the partial hospitalization level of care on September 18, 2024 and discharged on November 29, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated August 08, 2024, was offered to the client.
Client #14 was admitted to the partial hospitalization level of care on February 05, 2025 and was discharged on April 15, 2025. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated February 05, 2025, was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Pyramid Healthcare has submitted a ticket into its health records system to add an enhancement. This enhancement will denote that a copy of the Consent for Treatment, Payment and Healthcare Operations consent is offered to the client and will be memorialized and maintained in the client record. This denote will be a required field at the bottom of the document. As a result, staff will be unable to move forward to complete the document without the review and acknowledgement of whether a copy was offered to the client or not. Compliance monitors on a monthly basis the completion of the Consent for Treatment, Payment and Healthcare Operations consent for all clients active in treatment. The monitoring information is shared with the facilities operations and clinical leadership team through a scorecard to review and identify if any client receiving care may be missing one. If clients are determined to be missing a document, facility leadership and/or designee will be responsible for ensuring completion of the Consent for Treatment, Payment and Healthcare Operations consent with those clients and offering a copy.
Executive Director and Clinical Supervisor will re-educate staff on the expectation to offer a copy of the Treatment, Payment and Healthcare Operations consent to each client and document that offering on the updated consent form in Staff Meeting by 8/14/25. This re-education will be recorded in the meeting minutes/notes.
In order to monitor compliance with our plan of correction, the Clinical Supervisor will be responsible for weekly supervision with direct care staff to ensure compliance. Executive Director will supervise the Clinical Supervisor weekly to monitor the plan of correction. Executive Director will provide updates to the Regional Director bi-weekly to ensure compliance with plan of correction. |