INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 20, 2009 and October 21, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc. Quakertown 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 20, 2009.
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during the physical plant tour, the facility failed to ensure that individual counseling sessions could not be observed.
The findings include:
During the physical plant tour on October 20, 2009 it was observed that an individual office assigned to counselor #8 lacked window coverings to ensure privacy so that individual counseling sessions could not be observed. The office had a window to the exterior perimeter of the facility. There were steps with a railing leading to this window. Any person that was outside of this particular office could walk up to the window and observe counseling sessions..
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Plan of Correction
705.4 (3)
Window coverings were placed on counselor office # 8 to maintain privacy on 10/20/09. Maintenance Personnel will ensure ongoing compliance during weekly inspections that will be documented in a "weekly inspection log."
Completion Date: 10/20/09
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
During the physical plant tour it was observed that the facility failed to provide ventilation in two bathrooms.
The findings include:
On October 20, 2009 during the physical plant tour it was observed in two bathrooms in the women's wing did not have working exhaust fans.
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Plan of Correction
705.6 (5)
Maintenance Personnel installed exhaust fans in the bathrooms on the female unit at the facility on 10/21/09.
Completion Date: 10/21/09
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709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. 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 client records, the facility failed to document short and long-term goals as formulated by both staff and client in six out of seven client records.
The findings include:
Seven client records were reviewed on October 20 through 21, 2009. Short and long-term goals in the individual treatment and rehabilitation plan were required in seven client records. The facility did not document long-term goals as formulated by both staff and client in records #2, 3, 4, 5, 6 and 7. The facility only documented short term goals formulated with the client and staff in these records.
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Plan of Correction
709.52
The Clinical Supervisor will meet with all counselors at the facility and conduct a training on documenting both short term and long term goals on treatment plans. The Clinical Supervisor will assure compliance with this standard through monthly chart audits and regularly scheduled supervision with the counselors. Target Date for final completion is 12/1/09.
Completion Date: 12/1/09
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records and facility policy and procedure manual, the facility failed to document treatment plan updates per the company policy guidelines in five of seven client records.
The findings include:
Seven client records were reviewed on October 20 through October 21, 2009. According to the facility's policy and procedure manual, policy number PC 2.15, P3.20, PC. 4.20, PC 4.30, PC 4.40, PC 4.50, PC 4.50, PC. 4.60, PC. 4.70, PC. 4.80, PC . 5.10, PC 6.10, PC 6.30, PC 10.10 dated 02-23-00 and last reviewed on 3-01-09, Section I, subsection 3, stated "Adolescent Short-term Residential program (Ridgeview; Brookside) - every 14 days after the initial case consultation." Treatment plan updates were required in seven client records. The facility documented late treatment plan updates in client records #1 and 4. The facility failed to document treatment plan updates in records # 1,2, 3, 4 and 7.
In client record # 1 the client's case consultation was completed on 8/20/2009. The treatment plan update was due on 9/3/2009. However, the facility failed to document a treatment plan update until 9/9/2009. This treatment plan update was six days late. An additional treatment plan update was due on 10/1/2009. The facility failed to document a treatment plan update until 10/9/2009. This treatment plan update was eight days late. Additionally, the facility failed to document a treatment plan that was due on 10/15/2009.
In client record #2 the case consultation was completed on 9/21/2009. The facility failed to document the treatment plan update that was due on 10/19/2009.
In client record # 3 the case consultation was completed on 9/14/2009. The facility failed to document the treatment plan update that was due on 10/12/2009
In client record # 4 the case consultation was completed on 4/2/2009. The treatment plan update was due on 4/16/2009. The facility failed to document a treatment plan update until 4/23/2009. This treatment plan update was seven days late. The facility failed to document treatment plan updates on 4/30/2009, 5/14/2009, 5/28/2009, 6/11/2009, 6/25/2009, 7/9/2009, 7/23/2009, 8/6/2009, 8/20/2009, 9/3/2009, and 9/17/2009.
In client record # 7 the case consultation was completed on 4/28/2009. The client was discharged on 5/28/2009. The facility failed to document any treatment plan updates in this client record. Treatment plan updates were due on 5/12/2009 and 5/26/2009.
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Plan of Correction
709.52 (b)
The Clinical Supervisor will review the policy and procedure with the counselors and ensure compliance with this standard through monthly chart audits and regularly scheduled supervision sessions with the counselors. The Program Director will provide an additional training to the counselors in regards to Treatment Plan Reviews. Target Date for final completion is 12/14/09.
Completion Date: 12/14/09
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document the date of completion of the discharge summary in two of four client records reviewed.
The findings include:
Seven client records were reviewed on October 20-21, 2009. Discharge summaries were required to be documented in four of the client records. Discharge summaries are required to be documented within one week of discharge. Two of four discharge summaries did not include documentation of the completion date, therefore, it is unable to be determined if they were completed within the one week time frame.
Record #4 was admitted on April 9, 2009 and discharged on September 25, 2009. The discharge summary was due by October 2, 2009. The discharge summary was documented, but it did not include the date it was completed.
Record #5 was admitted on July 7, 2009 and discharged on July 23, 2009. The discharge summary was due by July 30, 2009. The discharge summary was documented, but it did not include the date it was completed.
Record # 6 was admitted on September 25, 2009 and discharged on October 4, 2009. The discharge summary was due by October 11, 2009. The discharge summary was documented, but it did not include the date it was completed. An interview was conducted with the Facility Director at 10:30 AM. on October 21, 2009 and he confirmed that the discharge summaries did not have a date of completion documented. The facility director was able to show that the discharge summary for record #6 was completed on October 5, 2009 by showing the tracking on the computer, however, he was unable to show when the other two discharge summaries were completed by viewing properties and information provided on the computer.
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Plan of Correction
709.53 (a)(10)
The Program Director and Electronic Medical Records Coordinator will ensure that the discharge summary is amended so there is a place for the date to be entered on all Discharge Summaries. The Clinical Supervisor will monitor for compliance during monthly chart audits. In addition, the Medical Records personnel will ensure that all discharge summaries are dated during weekly chart monitoring. Target Date for completion is 11/23/09.
Completion Date: 11/23/09
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in four of four client records.
The findings include:
Seven records were reviewed on October 20 through 21, 2009. Follow-up information was required in four client records. The facility did not document follow-up information in client records # 4, 5, 6, and 7.
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Plan of Correction
709.53(a)(11)
The Program Director will review the current policy and procedure that addresses follow-up contact on all clients discharged from each level of care within seven days with the Medical Records Personnel. The Medical Record Personnel will make sure that follow-up calls are placed within the appropriate time frame. The Clinical Supervisor will monitor for compliance by completing monthly chart audits. Target date for final completion is 12/21/09.
Completion Date: 12/21/09
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