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 28-30, 2009 licensure renewal inspection. The follow-up inspection was conducted on March 29, 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 April 21, 2010.
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Plan of Correction
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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 training hours, the facility failed to document the completion of 25 clock hours of annual training required for one of four counselors. A plan of correction follow up was completed on March 29, 2010, and the same employee that failed to document 2008 training hours, also failed to document 2009 training hours.
The findings include:
A plan of correction follow up was completed on March 29, 2010, and the same employee that failed to document 2008 training hours, also failed to document 2009 training hours.
Four training records were reviewed on March 29, 2010. All four records reviewed were counselors. Four counselors were required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training for employee # 4.
Employee # 4 was hired on January 28, 2004. The facility training year is from January through December. The training year for January 2009 to December 2009 was reviewed. Employee # 4 did not complete any clock hours of annual training in 2009.
The Program Director confirmed on March 29, 2010 that the counselor did not have the 25 clock hours of training for the 2009 training year.
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Plan of Correction
All counselors will have the completed 25 hours of required trainings annually.
The Program Director has developed a training plan with this employee to ensure 25 hours of training will be received within the current training year. Attendance to each training will be documented by HR and the program director as they occur to ensure compliance. Any missed trainings will be discussed with the employee during supervision and re-scheduled as appropriate. |
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 the three required records, and failed to document a treatment plan update within 30 days in one of three client records.
The findings include:
A plan of correction follow up was completed on March 29, 2010. Ten client records were reviewed on March 29, 2010. Six of the ten client records were from the partial activity. Three of those six records were required to document a treatment plan update. A treatment plan update was not documented in one of the three required client records. A treatment plan update was documented late in one of the three required client records. The treatment plan update policy states the treatment plan for acute partial client records will be updated weekly, and partial client records will be updated every 30 days.
Client # 1 was admitted on 12-16-09 and was discharged on 1-27-10. The treatment plan was completed on 12-21-09. The treatment plan update was due on 1-21-10, but was not documented.
Client #4 was admitted 2-2-10. The treatment plan was completed on 2-5-10. The treatment plan update was due on 3-5-10, but was not included in the record at the time of the plan of correction follow-up survey on 3-29-10. The counselor was able to provide the update.
Client #10 was admitted to Acute Partial Hospitalization on 1-6-10. The treatment plan was completed 1-8-10. The treatment plan update was due within seven days and was completed on 1-15-10. The client transferred to partial hospitalization on 1-22-10, and then transferred to intensive outpatient on 2-10-10. The next treatment plan update was due on 2-15-10, but was completed late on 2-18-10.
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Plan of Correction
The lead counselor and program director will continue to conduct random monthly chart monitors for each counselor to monitor the timely completion of treatment updates. Any deficient reviews will be addressed with the counselor by the program director during 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 two of the three required records.
The findings include:
Ten client records were reviewed on March 29, 2010. Six of the ten 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 two of three client records. Per the facility policy, follow up on clients is to be completed within seven days of discharge.
Client # 1 was admitted on 12-16-09 and discharged on 1-27-10. The follow up attempt was due on 2-5-10, and was not documented.
Client # 2 was admitted on 12-7-09 and discharged on 1-8-10. The follow up attempt was due on 1-19-10, and was not documented.
The director confirmed on March 29, 2010 that the follow up was not completed.
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Plan of Correction
All counselors in the partial hospitialization programs will be required to submit aftercare follow-up documentation to the program director within 2-5 days of discharge, according to policy. The program director will monitor discharges through the client tracking log to ensure timely submission. Any deficient submissions will be addressed with the counselor during supervision. |
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 two of the three required records.
The findings include:
Ten client records were reviewed on March 29, 2010. Four of the sixteen client records were from the outpatient activity. Three of those four records were required to document follow-up attempts. Follow up was not documented in two of the three required client records.
Client # 7 was admitted on 12-16-09 and discharged on 2-1-10. The follow up attempt was due on 2-10-10, and was not documented.
Client # 8 was admitted on 12-16-09 and discharged on 2-24-10. The follow up attempt was due on 3-5-10, and was not documented.
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Plan of Correction
All outpatient counselors will be required to submit aftercare follow-up documentation to the program director within 5 days of discharge. The program director will monitor discharges through the client tracking log to ensure timely submission. Any deficient submissions will be addressed with the counselor during supervision. |