INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24, 2019 through September 25, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirement Facility Summary Report, it was determined that the project failed to comply with the client/counselor ratios. The project exceeded the maximum caseload permitted for one of the eight clinicians reviewed at the project. Employee #5 was hired on July 2, 2018 and was still acting in that position at the time of inspection. Employee #5 reported to have 40 hours per week devoted to their 42 clients on their caseload. The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the hours worked weekly. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.The FTE counselor's caseload calculation is as follows: 40/40 = 1(FTE); 42/1 = 42, which equals to a client/counselor ratio of 42/1.This is a repeat citation from last year's licensure renewal inspection. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
At the time of inspection, our program was understaffed by 1 FTE. The new counselor began work on 9/30/19 but at the time of inspection, one of our FT counselors was assigned by our Clinical Supervisor the primary responsibility for 1 group of clients previously on the caseload of a recently departed staff member, increasing her caseload by 12 to 42/1 ratio. This was a temporary solution to prevent disruption of care to those client's whose counselor had left the program unexpectedly. On 9/30/19, this group of 12 clients was transferred to the new counselor, bringing all counselors within the 35/1 ratio.
To prevent this problem in the future, when a staff member leaves the program or announces their resignation, the Clinical Supervisor and Program Director will meet and reassign the caseload across staff members to assure that no-one exceeds the 35/1 ratio. Responsible Party: Program Director and Clinical Supervisor. Date of Completion: Within 1 week of knowledge of departure of staff.
If the program does not have capacity to transfer cases without exceeding the client/counselor ratio, one of the following strategies will be employed:
a. Determine if a staff person is available to transfer a counselor from another Pyramid Healthcare location temporarily until a new counselor can be hired. Responsible Party: Program Director. Date of Completion: Within 1 week of knowledge of capacity issue.
b. The Clinical Supervisor will take on the caseload and the client's direct service and primary counselor functions temporarily until a new counselor can be hired. The Program Director will take over Clinical Supervision during that time. Responsible Party: Clinical Supervisor and Program Director. Date of Completion: Within 1 week of knowledge of departure of staff.
While this is a repeat violation of the same regulation, last year's violation was regarding the number of clients that could be served by our FT Clinical Supervisor.
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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 the review of client records, it was learned that the project failed to obtain an informed and voluntary consent for client #10.Client #10 was admitted on April 9, 2019 and was an active client at the time of the inspection. A consent to release for the funding source was completed, however the client failed to sign the form. Additionally, there was email correspondences between project staff and a judicial service without a completed an informed and voluntary consent to disclose form. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In order to correct this deficiency, attempts were made to contact the client to correct the errors, but he is no longer available at the phone or address that was provided at the time of treatment.
In order to prevent this error from happening again, the following steps are being taken:
1. A review of how to appropriately complete a consent form, and confidentiality regulations as they relates to consent forms was done by the Program Director in All Staff Meeting on 10/24/2019.
2. Completion of informed and voluntary consents is the responsibility of the Assessment Counselor at the time of admission for all needed consents known at that time. If additional consents are needed during the course of treatment, they are the responsibility of the Primary Counselor. Any staff member releasing information is responsible for insuring that a valid consent is in place that allows the disclosure. These responsibilities were reviewed by the Program Director at the All Staff meeting on 10/24/19.
3. The Assessment Supervisor will monitor consent forms completed at the time of assessment to assure that the correct forms have been completed and that they are completed correctly. Responsible Party: Assessment Supervisor Time Frame: Ongoing weekly review of all new admissions files beginning 10/28/19.
4. The Clinical Supervisor will monitor to assure that the disclosure of any confidential information by counselors is done according to regulation and within the restrictions of any signed consent form. The Clinical Supervisor will conduct a case review with each counselor monthly to review that any disclosures to outside parties was done properly. Responsible Party: Clinical Supervisor. Time Frame: Chart review with counselor 1x/month beginning 10/28/19.
5. All Accepted plans of correction will be gone over with all staff in the All Staff meeting immediately following their acceptance. Responsible Party: Program Director. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, it was determined that the project failed to document the name of the person, agency or organization to whom disclosures would be made in client record #6.Client #6 was admitted on February 5, 2019 and was discharged on March 18, 2019. This client's record contained a blank consent to release information form signed by the client on February 26, 2019.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Though the client for which this error occurred has been discharged, a request was made by the Program Director on 10/25/19 to the IT department to have the incomplete consent form removed from the client's record.
In order to prevent the error from happening again, the following steps are being taken:
1. A review of how to appropriately complete a consent form, and confidentiality regulations as they relate to consent forms was completed by the Program Director in All Staff meeting on 10/24/19.
2. The Assessment Supervisor will monitor all consent forms completed at the time of assessment to assure that they are completed correctly and that no black or incomplete consent forms are in the record. Responsible Party: Assessment Supervisor. Time Frame: Ongoing weekly review of all new admission files beginning 10/28/19.
3. The Clinical Supervisor will monitor to assure that any additional consent forms obtained by counselors during the course of treatment are completed properly. The Clinical Supervisor will conduct a case review with each counselor monthly to review confidential releases and forms. Responsible Party: Clinical Supervisor. Time Frame: 1x/month with each counselor beginning 10/28/19. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to provide written notification of the decision to involuntarily terminate the client's treatment in client records #6 and #8.Client #6 was admitted on February 5, 2019 and involuntarily discharged on March 18, 2019. There was no documentation in the client's records that the client received written notification of the involuntary termination. Client # 8 was admitted on December 20, 2018 and involuntarily discharged on February 13, 2019. There was no documentation in the client's records that the client received written notification of the involuntary termination. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. A discharge letter with written notification of the decision to involuntarily terminate the client's treatment will be completed to the clients that were missing this notification (#6 & #8). Responsible Party: Clinical Supervisor Time Frame: 10/31/2019.
2. In order to prevent this problem from reoccurring, the Clinical Supervisor will review a report of all clients discharged (by discharge type) each month and check to be sure that any client who was involuntarily terminated from treatment received a letter or notification. Responsible Party: Clinical Supervisor. Time Frame: monthly beginning 10/31/19. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to update treatment and rehabilitation plans at least every 60 days in three out of seven records reviewed.Client #1 was admitted on December 20, 2018 and was an active client at the time of the inspection. A treatment and rehabilitation plan update was missing between March 26, 2019 and June 19, 2019.Client #10 was admitted on April 9, 2019 and was an active client at the time of the inspection. There were no treatment and rehabilitation plan updates after the initial treatment plan created on April 14, 2019.Client #12 was admitted on October 11, 2017 and discharged on March 22, 2019. There were no treatment and rehabilitation plan updates after September 26, 2018 documented in this client's record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our analysis of how these errors happened and how we can prevent it from happening again, revealed that all three of these cases involved transfers to different therapists and this created some confusion on the part of the "new" therapist with regard to who was responsible for the undone/next treatment plans. In one of these cases, the client did not continue in treatment but was not discharged in a timely fashion resulting in treatment plans being out of date.
Our plan of action to assure that the problem does not happen again is the following:
1. Our Electronic Record system provides an "alert" for upcoming due dates for critical components of the record including treatment plan due dates. The alert system will prevent any confusion re: whose responsibility it is to complete the plan in cases that have been transferred to a different counselor. The counselors will review their alerts weekly to be able to anticipate upcoming due dates and to assure timely completion. Responsible Party: Counselors. Date of Completion: weekly ongoing beginning 10/14/19.
2. The Clinical Supervisor also has access to the "alert notifications" of staff that she supervises and will review the alerts for each of her supervisees to monitor/oversee that each week's responsibilities were completed from the week before. Responsible Party: Clinical Supervisor. Date of Completion: ongoing weekly beginning 10/14/19.
3. In any situation that the counselor does not complete their responsibilities by the due date, they will be called on to complete it that day, and if that is not possible will be completed by the Clinical Supervisor. Responsible Party: Clinical Supervisor. Date of Completion: ongoing weekly beginning 10/14/19.
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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 the review of client records, it was determined that the project failed to assure counseling services were provided according to the individual treatment and rehabilitation plan in four out of seven client records reviewed.Client #1 was admitted on December 20, 2018 and was active at the time of the inspection. Treatment and rehabilitation plans created on December 19, 2019, January 14, 2019, February 13, 2019, March 26, 2019, June 19, 2019 and August 28, 2019 all indicate that the client was to receive individual counseling "monthly" and group counseling "weekly." There was no documentation that the client was provided individual counseling required per the treatment and rehabilitation plan for the months of December 2018, January 2019, March 2019, April 2019, May 2019, June 2019 and July 2019. Additionally, there was no documentation that the client was provided two out of four group counseling sessions required per the treatment and rehabilitation plan for the month of June 2019, three out of four group counseling session required per the treatment and rehabilitation plan for the month of July 2019 and two out of four group counseling sessions required per the treatment and rehabilitation plan for the month of August 2019.Client # 2 was admitted on July 17, 2019 and was active at the time of the inspection. A treatment and rehabilitation plan created on July 31, 2019 indicated that the client was to receive group counseling daily. Treatment and rehabilitation plans created on August 19, 2019 and September 15, 2019 indicated that the client was to receive group counseling three times a week. There was no documentation that the client was provided five out of twelve group counseling sessions required per the treatment and rehabilitation plan in the month of August 2019 and three out of nine group counseling sessions required per the treatment and rehabilitation plan in the month of September 2019.Client #10 was admitted April 9, 2019 and was active at the time of inspection. A treatment and rehabilitation plan created on April 16, 2019, indicated that the client was to receive group counseling sessions three times a week and individual counseling sessions monthly. There is no documented contact with this client after May 28, 2019; therefore, the client was not provided any group counseling services and individual counseling services required per the treatment and rehabilitation plan from the months of June 2019 through September 2019.Client #12 was admitted on October 11, 2017 and was discharged on March 22, 2019. The last treatment and rehabilitation plan completed on this client was on September 26, 2018. This treatment and rehabilitation plan indicated that the client was to receive individual counseling "weekly." There was no documentation that the client was provided two of the four individual sessions required per the treatment and rehabilitation plan for the month of October 2018, two out of four individual counseling sessions required per the treatment and rehabilitation plan for the month of November 2018 and three out of four individual counseling session required per the treatment and rehabilitation plan for the month of December 2018. There is no documented contact with this client after December 19, 2018; therefore, there is no documentation that the client was provided individual counseling required per the treatment and rehabilitation plan from the months of January 2019 through March 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.Primary Counselors are responsible for contacting clients who do not show up for scheduled groups or treatment activities the day following their absence to encourage their return to care and to address any barriers preventing participation. This contact or attempt is to be documented in the client record as a "memo to chart". This responsibility will be reviewed with all Counselors in All Staff meeting on 10/30/19. Responsible Party: Program Director. Time Frame: 10/30/19
2. The Clinical Supervisor will review group attendance reports every other week to identify and assure that clients that have not attended are being contacted by the Primary Counselor per our practice. Responsible Party: Clinical Supervisor. Date of Completion: weekly /ongoing beginning week of 11/04/19.
3. On a monthly basis, the Clinical Supervisor will run a report from our Electronic Medical Record on "active clients not seen for 30 days" to identify any clients who have not been reengaged in care, to assure that documented attempts have been made to reengaged and to assure that discharges are completed promptly. The Clinical Supervisor will assure that the Counselor completes any missed discharges. Responsible Party: Clinical Supervisor. Date of Completion: Monthly ongoing beginning 11/1/19.
4. The Clinical Supervisor will run a monthly report of Individual Sessions provided to each client and compare this to the treatment recommendation. Any client not being provided the treatment recommended will be reviewed in individual supervision to identify and address any issues preventing service delivery to to develop and implement and action plan to bring the service levels into compliance. Responsible Party: Clinical Supervisor. Time Frame: Monthly ongoing beginning 11/1/2019.
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