INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 29, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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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.
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Observations
Based on one of eleven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record # 7. Client # 7 was admitted on March 27, 2023 and was discharged July 24, 2023. Authorizations for a funding source occurred on April 7, May 5, and June 9, 2023. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to this funding source.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On October 2nd 2023, staff were re-trained by the Executive Director on proper completion of releases of information including how to locate and confirm a client's funding source in order to complete the proper consent. All new hires will complete Confidentiality training which includes completion of consents in Relias. Additionally, the utilization review team will be confirming releases of information for funding prior to requesting authorizations. The utilization review coordinator will contact the site to inform if a proper release of information is needed. The Regional Quality Management team will also conduct monthly chart audits that includes review if releases of information are completed based off applicable licensing and funder expectations. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on four of eleven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed but instead allowed the "entire record" to be disclosed.Client # 1 was admitted on February 10, 2023 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated August 24, 2023 to a funding source did not provide the specific information that was to be disclosed. Client # 3 was admitted on July 27, 2023 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated July 27, 2023 to a funding source and two county agencies did not provide the specific information that was to be disclosed. Client # 6 was admitted on June 20, 2023 and was discharged August 3, 2023. An informed and voluntary consent from the client for the disclosure of information dated June 20, 2023, July 19, 2023, and July 27, 2023 to funding sources did not provide the specific information that was to be disclosed. Client # 8 was admitted on July 13, 2023 and was discharged August 8, 2023. An informed and voluntary consent from the client for the disclosure of information dated July 13, 2023 to a funding source and parole office did not provide the specific information that was to be disclosed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director conducted a training on completion of the Release of Information (ROI) with staff members during a staff meeting on October 2nd, 2023. During this meeting, the Executive Director reviewed a process shift in the ROI completion. The training will review the need to discontinue selecting "Entire Record" on Releases of Information at this time. The change will be effective after the training.
Our Quality Specialist Team continues to complete monthly chart monitors and looks at the completion of Releases of Information. They will ensure that "Entire Record" for this program is not selected during their monitors. After the monthly monitors are completed, the facility leadership is met with to review the results of the audits and facility leadership will use this review to continue to keep an eye on these items as well.
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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 one of one applicable partial client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur seven days from discharge.Client # 10 was admitted on March 20, 2023 and was discharged on April 6, 2023. There was no follow-up information available in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Pyramid Healthcare written policy for client discharge from the program is that all clients will be called within 7 days of the discharge date. To ensure proper completion of the 7-day follow-up calls, the director will pull a discharge list for all clients discharged the week prior and present this list at weekly staff meeting. All staff will be provided with their list of clients to contact. Clinical supervisor will do an end-of-the-week audit on 50% of the discharge list and confirm the call logs are completed. This will occur through March 31st 2024. The Regional Quality Management team will also conduct monthly chart audits that includes if reengagement or follow up call was documented post-discharge. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on three of nine outpatient client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records # 4, 5 and 7. Client # 4 was admitted on March 28, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on April 11, 2023 indicated an individual session occur biweekly and a group session occur weekly. A treatment plan update occurred June 13, 2023 and indicated an individual session occur biweekly and a group session occur weekly. A treatment plan update on June 20, 2023 indicates an individual session and group session occur monthly. A review of progress notes and record of service did not document group sessions after June 13, 2023.Client # 5 was admitted on February 23, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on February 23, 2023 indicated an individual session occur monthly and group sessions occur three times a week. A treatment plan update occurred May 9, 2023 and indicated an individual session occur weekly and a group session occur monthly. A treatment plan update on June 13, 2023 indicates an individual session and group session occur monthly. A review of progress notes and record of service did not document individual sessions weekly the weeks of: May 14-20, May 28-June 3, and June 4-10, 2023 or group sessions three times a week the weeks of: March 1-31, March 5-11, March 12-18, March 19-25, March 26-31, April 2-8, April 9-15, April 16-22, and April 23-29, 2023.Client # 7 was admitted on March 27, 2023 and was discharged July 24, 2023. A comprehensive treatment and rehabilitation plan developed on March 27, 2023 indicated an individual session occur biweekly and group sessions occur three times a week. A treatment plan update occurred April 7, 2023 and indicated an individual session occur biweekly and a group session occur three times a week. A treatment plan update on June 9, 2023 indicates an individual session and group session occur monthly. A review of progress notes and record of service did not document individual sessions biweekly the weeks of: April 16-29 and May 14-27, 2023 or group sessions three times a week the weeks of: April 2-8, April 9-15, April 16-22, April 23-29, April 30-May 6, May 7-13, and May 14-June 3, 2023. The last documented individual session occurred on June 9, 2023 and the last group session was documented on June 21, 2023.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the August 24, 2022 annual licensing inspection.
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Plan of Correction
On 01/29/2024, clinical supervisor will conduct a group supervision to address clients receiving counseling services according to their treatment plan. Staff will be advised that after initial assessment or intake, all clients should be placed on a recurring group roster. Additionally, at the conclusion of every individual session, the client should leave with another individual session scheduled. The clinical supervisor will review assessments/intakes from previous week at the weekly staff meeting to ensure clients are placed on the appropriate rosters. At monthly supervision, the clinical team will conduct a chart audit for service compliance on 10% of the outpatient caseload through April 30th, 2024. The Regional Quality Management team will also conduct monthly chart audits that includes if frequency of individual and group sessions offered and completed in accordance with applicable state and funder expectations. |