INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 28-30, 2009 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 28, 2009.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, a review of the facility summary report, and a conversation with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training for two of six personnel.
The findings include:
The facility summary report was reviewed on October 2, 2009. Ten personnel records were reviewed on October 2, 2009. Six personnel were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for two personnel records, # 9 and 10.
Employee # 9 is a counselor and was hired August 25, 2008. HIV/AIDS and TB/STD training was to be completed within one year of hire, by August 25, 2009. The facility failed to provide documentation of TB/STD training as of October 30, 2009.
Employee #10 is a support staff and was hired May 7, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by May 7, 2009. The facility failed to provide documentation of TB/STD training as of October 30, 2009.
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Plan of Correction
The 2 specific staff will complete the HIV/AIDS and TB/STD trainings as scheduled as soon as available and by 3/16/10.
Certificates of completion will be copied for Program Director and placed in personnel records within a week of completion of training.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records reviewed.
The findings include:
Ten personnel records were reviewed on October 2, 2009. One personnel record was a counselor. One personnel record was required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 7.
Employee # 7 was hired on January 28, 2004. The facility training year is from January through December. The training year for January 2008 to December 2008 was reviewed. Employee # 7 only completed 6 clock hours of annual training in 2008.
The Human Resource Director confirmed on October 7, 2009 at 2:00 PM that the counselor did not have the 25 clock hours of training for the 2008 training year.
The Program Director confirmed on October 29, 2009 at 1:30 PM that the counselor did not have the 25 clock hours of training for the 2008 training year.
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Plan of Correction
All counselors will have the completed 25 hours of required trainings annually.
Each counselor will complete a training plan for the year. The Program Director will review and follow up with each counselor in weekly supervision regarding their training plan, attendance and completion of trainings to insure timely completion of the 25 hours needed each year.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in one of one client records.
The findings include:
Sixteen client records were reviewed on October 28, 29 and 30, 2009. Six of the sixteen client records were from the partial activity. One of those six records was required to document a treatment plan update. A treatment plan update was not documented in one of one client records. The treatment plan update policy states the treatment plan for acute partial client records will be updated weekly.
Client record # 4 included documentation of an admission date of 9-16-09. The treatment plan was completed on 9-18-09. The treatment plan updates were completed on 9-21-09 and 9-28-09. The updates were completed within the weekly time frame, but did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan. Both treatment plan updates, 9-21-09 and 9-28-09, were the same and did not include any updates regarding the progress of completing the goals of the treatment plan.
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Plan of Correction
The Program Director will conduct an overview of writing treatment plans and treatment plan updates for all staff by 12/15/09.
The Lead Counselor and Program Director will conduct random chart monitors monthly for each Partial counselor to review for timely completion and documentation of clients' progress in each treatment plan update.
Any chart monitor that falls below 85% will be reviewed with the counselor in weekly supervision.
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709.83(a)(11) LICENSURE Client records
709.83. 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 a review of client records, the facility failed to document follow-up attempts in three of the three required records.
The findings include:
Sixteen client records were reviewed on October 28, 29 and 30, 2009. Six of the sixteen client records were from the partial hospitalization activity. Three of those six records were required to document follow-up attempts. Follow up was not documented in three of the three required client records. The follow up policy states the facility staff will contact the client within seven days after discharge.
Client record # 4 was admitted on 9-16-09 and discharged on 9-29-09. The follow up attempt was due on 10-6-09. There was no documentation of a follow up attempt as of 10/27/09.
Client record # 5 was admitted on 10-2-09 and discharged on 10-7-09. The follow up attempt was due on 10-14-09. There was no documentation of a follow up attempt as of 10/27/09.
Client record # 6 was admitted on 9-9-09 and discharged on 9-15-09. The follow up attempt was due on 9-22-09. There was no documentation of a follow up attempt as of 10/27/09.
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Plan of Correction
The Program Director will re-orient and train all clinical staff on completing follow-up of discharged clients (within 7 days of discharge) on 11/18/09.
The Program Director will instruct all staff to submit follow-up documentation for the first 60 days after the in-service on 11/18/09 and thereafter, the Program Director and Lead Counselor will review completion of follow-ups during monthly chart monitors. Any missing documentation of follow ups will be reviewed in weekly supervision with the clinician.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information in four of twelve client records.
The findings include:
Sixteen client records were reviewed on October 28, 29 and 30, 2009. Twelve of those sixteen records were required to document an informed and voluntary consent from the client for the disclosure of information. Written consent to release information forms found in three client records did not indicate the specific information to be disclosed. One client record included another clients full name in two progress notes which were documented for that client.
Client record # 1 includes an admission date of 10-9-09. The written consent to release information was for a release of information to a three quarter way house, but did not include documentation of the specific information to be disclosed. That section of the release form was blank.
Client record # 2 includes an admission date of 10-9-09. The written consent to release information form was for a release of information to a drug court, but did not include documentation of the specific information to be disclosed. That section of the release form was blank.
Client record # 12 includes an admission date of 8-31-09. The written consent to release information was for a release of information to a mobile medical unit, signed on 8-28-09, but did not include documentation of the specific information to be disclosed. That section of the release form was blank. Client record # 12 also included a consent to release information form which was signed on 8-28-09 for a release of information to a private physician, but did not indicate the specific information to be disclosed.
Client record # 13 includes an admission date of 9-14-09. Client record #13 includes two acute partial hospitalization activity progress notes which are dated 9-4-09 and 9-16-09, but are another client's progress notes. These two progress notes include another clients full name, client identification number and the content of these two therapy sessions.
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Plan of Correction
The Program Director will review confidentiality and correct completion of release of information will all staff by 12/30/09.
Each staff will sign off that they attended the training.
During monthly chart monitors the Program Director and Lead Counselor will review all the releases of information for accuracy.
Any inaccurate releases of information will be reviewed with the counselor in weekly supervision.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up attempts in five of five client records.
The findings include:
Sixteen client records were reviewed on October 28, 29 and 30, 2009. Ten of the sixteen client records were from the outpatient activity. Five of those ten records were required to include documentation of follow-up attempts. Follow up was not documented in five of five client records. The follow up policy states the facility staff will contact the client within seven days after discharge.
Client record # 7 includes an admission date of 9-3-09 and a discharge date of 10-15-09. The follow up attempt was due on 10-22-09. There was no documentation of a follow up attempt as of 10/30/09.
Client record # 12 includes an admission date of 8-31-09 and a discharge date of 9-15-09. The follow up attempt was due on 9-24-09. There was no documentation of a follow up attempt as of 10/30/09.
Client record # 13 includes an admission date of 9-14-09 and a discharge date of 10-16-09. The follow up attempt was due on 10-27-09. There was no documentation of a follow up attempt as of 10/30/09.
Client record # 15 includes an admission date of 4-20-09 and a discharge date of 9-29-09. The follow up attempt was due on 10-8-09. There was no documentation of a follow up attempt as of 10/30/09.
Client record # 16 includes an admission date of 3-11-09 and a discharge date of 10-1-09. The follow up attempt was due on 10-12-09. There was no documentation of a follow up attempt as of 10/30/09.
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Plan of Correction
The Program Director will re-orient and train all clinical staff on completing follow-up of discharged clients (within 7 days of discharge) on 11/18/09.
The Program Director will instruct all staff to submit follow-up documentation for the first 60 days after the in-service on 11/18/09 and thereafter, the Program Director and Lead Counselor will review completion of follow-ups during monthly chart monitors. Any missing documentation of follow ups will be reviewed in weekly supervision with the clinician.
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