INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 21, 2019 licensure renewal inspection. The follow-up inspection was conducted on April 22, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 May 28, 2010.
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Plan of Correction
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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, an interview with the facility director, and facility policy and procedure manual, the facility failed to document treatment plan updates per the company policy guidelines in three of six client records.
The findings include:
Six client records were reviewed on April 22 2010. 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 three client records. The facility failed to document treatment plan updates every 14 days in client records # 4, 5 and 6.
Client # 4 was admitted to the program on 2/9/10. The comprehensive treatment plan was completed on 2/9/10. The treatment plan updates that were documented did not include the completion date.
Client # 5 was admitted to the program on 2/15/10. The comprehensive treatment plan was completed on 2/16/10. The treatment plan updates that were documented did not include the completion date.
Client # 6 was admitted to the program on 3/11/10. The comprehensive treatment plan was completed on 3/12/10. The treatment plan updates that were documented did not include the
completion date.
An interview with the facility director was conducted on April 22, 2010. The facility director stated that the computerized charting system is not capable of time stamping the updates.
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Plan of Correction
The Electronic Health Medical Record that the agency is currently using has been modified so the updates and reviews reflect completion dates. The clinical supervisor will review these changes with all clinical staff and monitor for compliance by completing monthly chart audits. The Clinical Supervisor will also ensure compliance through scheduled group and individual supervision with the clinical staff. Target date for completion is 5/28/10. |
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 one of four client records reviewed.
The findings include:
Six client records were reviewed on April 22, 2010. 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. One of four discharge summaries did not include documentation of the completion date, therefore, it is unable to be determined if it was complete within the one week time frame.
Client # 5 was admitted on 2/15/10 and discharged on 3/17/10.
The discharge summary was due by 3/24/10. The discharge summary was documented, but it did not include the date it was completed.
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Plan of Correction
The discharge summary form will be modified and a field for the date that the discharge summary is completed will be added. The Clinical Supervisor will review this change to the document with all clinical staff. Also, the Clinical Supervisor will monitor for compliance by completing monthly chart audits. Target date for completion is 5/21/10. |
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 and a review of the policy and procedures manual, the facility failed to document follow-up information in two of four client records.
The findings include:
Six records were reviewed on April 22, 2010. Follow-up information was required in four client records. The facility failed to document follow-up information within seven days from the date of discharge, as per facility policy, in client records # 3 and 5.
The facility's policy titled " Follow-up" states:
All clients who receive treatment through Pyramid are provided with follow up contact to verify on-going success or identify continuing care needs.
II. If a client is discharged with an aftercare appointment in place:
A. A designated staff member telephones the client's continuing care provider to verity that the initial aftercare appointment was kept.
1. OP client directly
III. If a client is discharged without an aftercare appointment arranged:
A. Within 7 days of discharge a designated staff member telephones the client to determine the level of aftercare needed and to provide referral if necessary.
Client #3 was admitted to the program on 9/11/09 and discharged on 2/3/10.
Client #3 had an OP after care appointment on 2/8/10, follow-up was documented on 2/12/10.
Client #5 was admitted to the program on 2/15/10 and discharged on 3/17/10.
Client #5 had an OP after care appointment on 3/17/10, follow-up was documented on 3/26/10.
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Plan of Correction
The current policy and procedure addresses follow-up contact on all clients discharged from each level of care, regardless of discharge status, and requires documentation of the follow-up attempt. Currently agency policy does not define a timeline for when the follow-up is to be placed to the client in regards to whether or not they attended the aftercare appointment. The agency will revise this policy and identify a timeline for when follow-up calls will be placed. The new policy will require that a follow-up call be placed to the client within (3) business days after the client's scheduled appointment. The Program Director will review the policy and procedure with the medical records department and monitor for compliance by completing monthly chart audits. Target date for final completion of this project is 5/21/10. |