INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 23 through 24, 2008 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 24, 2008.
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Plan of Correction
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704.12(a)(3)(ii) LICENSURE NonHosp Rehab/Adol
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(ii) Projects serving adolescent clients shall have one FTE counselor for every six clients.
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Observations
Based on a review of facility documentation on October 25, 2008, the facility failed to maintain a ratio of one counselor for every six adolescent clients.
Findings:
Based on full time equivalency staff hours versus client census the facility had a client to staff ratio of seven to one.
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Plan of Correction
704.12(a)(3) NonHosp Rehab/Adol
The Human Resource Director, Adolescent COO, and Program Director will actively recruit and hire additional counselors to ensure that the facility maintains the required client to counselor ratio of six to one. The Target date for final completion is 12/1/08.
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of eleven client records on October 23, 2008, the facility failed to document information to be disclosed in seven of seven client records where required.
Findings:
The facility did not list the specific information that would be disclosed on the consent to release information forms in client records # 1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
709.28(c) Confidentiality
The Clinical Supervisor will conduct training with all staff members that complete the admission paperwork at the facility. This training will ensure that the staff members are documenting specific information that would be disclosed on the consent to release information form. This documentation will be reviewed in monthly chart audits that are conducted by the Clinical Supervisor. Target date for final completion is 12/1/08.
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709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of eleven client records on October 23, 2008, the facility failed to document that copies of all consents to release information forms were offered to the client in four of seven client records where required.
Findings:
There was no documentation that clients were offered a copy of all consents to release information in client records # 1, 4, 5 and 6.
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Plan of Correction
709.28(d) Confidentiality
The Clinical supervisor will conduct a training with all staff members that conduct intakes at the facility as well as any staff members that assist with the admission process to ensure that it is documented that we have offered a client a copy of the consent to release information. This documentation will be reviewed in monthly chart audits that are conducted by the Clinical Supervisor. Target date for final completion is 12/1/08.
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709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of facility administrative documentation on October 24, 2008, the facility failed to ensure that medication storage areas were inspected monthly.
Findings:
The facility failed to document the inspection of drug storage areas from August 2008 through September 2008.
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Plan of Correction
709.32(c)(3) Medication Control
The Nurse Manager will inspect the medication storage areas by the fifth day of each month. The Program Director will ensure compliance by reviewing the inspections that will be detailed in the Facility nursing report that is completed monthly. Target date for final completion is 11/1/08.
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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 a review of eleven client records on October 23, 2008, the facility failed to document follow up attempts in four of five client records where required.
Findings:
The facility failed to document follow-up attempts in client records # 8, 9, 10 and 11.
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Plan of Correction
709.53(a)(11) Follow-up Information
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 which is to be made within seven days of the appointment date. The Clinical Director will review the policy and procedure with the counselors and monitor for compliance by completing monthly chart audits. Target date for final completion of this project is 1/15/09.
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